Self-insured or Employee Retirement Income Security Act (ERISA) governed plans have traditionally raised unique problems for physicians.

With a typical insurance product, the employer pays a premium to the insurance carrier or health plan, and that entity assumes the financial risk for claims incurred. Under a self-insured ERISA plan, the employer typically leases a large payor’s provider network and discounted reimbursement rates, but the employer assumes the actual risk of claims incurred.

This type of arrangement is referred to as “administrative services only” (ASO). Governed only by federal ERISA law, self-insured ERISA plans are not bound by the protections afforded to physicians under California’s Health Care Providers’ Bill of Rights or other state laws and regulations, which creates challenges in the areas of coverage determinations, claims payment and prior authorization.   

The California Medical Association (CMA) is working to address the unique challenges experienced by providers who provide care to patients with self-funded ERISA plans. If your practice has experienced challenges with self-funded ERISA payors, CMA wants to hear from you.  

Contact Mark Lane, director of CMA’s Center for Economic Services Director at (888) 401-5911 or mlane@cmadocs.org.

To learn more about ERISA, see CMA Health Law Library document #7505, “ERISA Plans.”