What types of insurance coverage are not subject to external review?
Self-Funded Coverage State external review programs do not apply when an employer offers “self-funded” health insurance to employees. However, some employers have voluntarily implemented an external review program. Your health plan is “self-funded” if your employer pays for the health care costs of its employees directly rather than purchasing coverage from an insurance company or other organization. Contact your employer, your human resources department or state department of insurance for assistance in determining whether your employer sponsored plan is insured or self-funded. Medicare or Medicaid Coverage State external review programs do not apply if you are covered by Medicare or Medicaid. If you are a Medicare beneficiary, you must follow the Medicare review process described in your Medicare Handbook. If you are a Medicaid beneficiary, you can ask your state or local Medicaid office about their appeal procedures. See a list of state Medicaid offices for more information.
