Hey there, We’re Shivang & Tania. Each week, we write in plain English (and some sass) about how health insurance works, why claims get denied, and how patients and healthcare teams can get paid or reimbursed. If you’re new here, we recommend you start with RCM 101: How Healthcare Gets Paid, Eventually, Maybe

Your insurance card contains useful information about your health coverage, but it may not identify every fact you need for a reimbursement question. Two people can have the same company name and PPO network while one has a fully insured employer plan and the other has a self-funded employer plan administered by that company. Those arrangements can fall under different regulatory frameworks. Where you live can matter too, although residence alone does not determine which state's insurance rules apply. The safer sequence is to identify the exact plan, identify the rule you are trying to use, and confirm that the rule reaches that plan.

Where this issue fits in the series:

In this issue, we cover:

It is Thursday morning at Dr. Singh's clinic.

Biscuit has an appointment. His friend Juno, a Dalmatian about his age, came with him because she is considering moving her care to the same practice. While they wait, Juno asks Sage at the front desk whether the clinic works with BHC's PPO network.

"BHC PPO?" Biscuit says. "That's what I have."

Juno looks over.

"Same insurance."

For most everyday conversations, that answer works. Biscuit's card says BHC PPO and Juno's card says BHC PPO. Both plans use our fictional BHC PPO network.

Sage has no reason to turn this into an investigation of how their employers finance healthcare.

In a real practice, insurance information may be collected during scheduling or registration. Providers can also send an electronic eligibility inquiry to a health plan. The response can provide information about eligibility and coverage, including deductibles, copays, coinsurance, and coverage information for particular types of services. Centers for Medicare & Medicaid Services

That serves an immediate purpose. It does not mean an ordinary eligibility response gives the practice every fact it could eventually need about the financial and regulatory structure of the plan.

Most of the time, nobody needs all of those facts. Then someone needs to answer a question that depends on the exact plan or the rule governing it. That is when "BHC PPO" may stop being enough.

Last week, one row in Sage's table asked, "What insurance plan does he have, exactly?"

This issue is about what can sit inside that deceptively simple question.

Before we talk about what the card may leave unresolved, the card deserves some credit.

It is useful and it helps identify the member and coverage. It can contain member and group information, the company involved, plan or network information, and instructions for contacting the plan.

So the lesson of this issue is not "don't trust your insurance card."

For Biscuit and Juno, the first unanswered question is where their coverage came from.

Both get health coverage through work. Biscuit works at Juniper Lane Design, a 22-person design studio. Juno works at Larkspur Freight, a private trucking company with about 3,000 employees.

So when Biscuit says, "I get my insurance through work," we have learned something useful.

We still do not know how Juniper Lane chose to finance those health benefits. That brings us to the first big split in our story.

Biscuit's employer buys a fully insured health plan from BHC. In a fully insured arrangement, the employer pays premiums to an insurance company. The insurer takes on the financial risk for covered claims under the insurance policy.

Juniper Lane pays premiums to BHC, with Biscuit contributing toward his coverage. BHC carries the financial risk for covered claims. Juno's employer chose another structure.

Larkspur Freight uses a self-funded health plan. In a self-funded arrangement, the employer pays for employees' health services from its own funds rather than purchasing health insurance that transfers that financial risk to an insurance company. Larkspur Freight carries the financial risk for Juno's health benefits.

This is common in employer coverage. KFF, a nonprofit health policy research group, reported that 67% of covered workers were enrolled in self-funded plans in 2025. The share was 80% among firms with 200 or more workers and 27% among firms with 10 to 199 workers. KFF

Now we know something the BHC name alone did not establish.

Readers of our appeals series may remember Margaret, Biscuit's mom. Her employer coverage was fully insured. Biscuit's current plan uses that same general funding structure. Juno's does not.

Yet Juno can still have BHC printed prominently on her insurance card. That is because paying for the benefits and administering the plan can be separate jobs.

Larkspur Freight is a trucking company. It does not need to build an insurance operation simply because it self-funds employee health benefits. An employer can hire another organization to perform administrative work. A company hired to do that is often called a third-party administrator, or TPA.

Depending on the arrangement, a TPA might process claims and answer member questions. It might provide access to a provider network or perform other administrative functions. The exact responsibilities depend on the contract. An insurance company can do this work too.

When an insurance company provides administrative services for a self-funded employer plan without taking on the underlying financial risk for the health benefits, you may hear the arrangement described as administrative services only, or ASO.

That gives fictional BHC two different jobs in our story. For Biscuit, BHC insures the plan. For Juno, BHC administers Larkspur Freight's self-funded plan.

Texas Department of Insurance guidance describes this general structure. TDI says a self-funded employer may hire an insurance company to handle claims and paperwork, and a member's card can say that the plan is "administered by" the company or use "ASO" for Administrative Services Only. Texas Department of Insurance

Each line tells us something different. Larkspur Freight is the employer sponsoring and funding the plan. BHC is administering it. And PPO tells us something else again.

Juno still has a perfectly reasonable question.

"If we're both BHC PPO, doesn't that mean something?"

Yes. PPO, IN PLAIN ENGLISH. PPO stands for Preferred Provider Organization.

A PPO is a type of provider-network arrangement. Members generally pay less when they use providers in the plan's network and can generally use out-of-network providers without a referral at additional cost.

For this issue: PPO tells us something about Biscuit and Juno's provider network. It does not tell us whether their employer plan is fully insured or self-funded.

Back in Medical billing 101, we used the in-network "door" to explain the relationship between a health plan and contracted providers.

PPO belongs on that side of the story.

KFF reported that 46% of covered workers were enrolled in PPOs in 2025. Another 33% were enrolled in high-deductible plans with a savings option, 12% in HMOs (Health Maintenance Organizations), and 9% in POS (Point of Service) plans. KFF

Now put our two friends next to each other:

The PPO label gives us useful network information. Funding answers another question.

This is how Biscuit and Juno can both truthfully say "BHC PPO" while different financial arrangements sit behind their cards.

By this point, we know quite a bit about Biscuit. He gets coverage through Juniper Lane Design. His plan is fully insured by BHC. It uses the BHC PPO network.

We know quite a bit about Juno too. She gets coverage through Larkspur Freight. Her employer self-funds the plan. BHC administers it, and the plan also uses the BHC PPO network.

For this issue, both Biscuit and Juno live in Texas. Now suppose someone finds a Texas insurance rule that appears relevant. Biscuit lives in Texas.

Does that mean the Texas rule applies to his plan?

We still cannot answer from his address alone.

The Texas Department of Insurance, or TDI, is the state agency that regulates insurance in Texas.

That does not mean every health plan covering a Texas resident falls under TDI's authority. TDI distinguishes between fully insured plans it regulates and private-sector self-funded employer plans that follow a different regulatory path. And there is another complication.

Living in a state does not automatically make every insurance rule from that state apply to your health coverage. The employer's headquarters is not a universal answer either. Where an insurance policy was issued can matter. Provider status can matter for some requirements.

Whether the employer plan is fully insured or self-funded can matter. And the particular law being researched can define which of those facts count.

So before asking: "What does Texas require?"

we need an earlier question: "Does this particular Texas rule apply to this particular plan and situation?"

That can change a reimbursement answer.

Texas prompt-payment rules give us a useful example. Imagine a patient who lives in Texas and receives care from a Texas provider. Her preferred provider health plan was issued in another state.

Do Texas prompt-payment rules automatically apply because both the patient and provider are in Texas?

TDI says no. For this particular rule, a preferred provider health benefit plan issued in another state does not become subject to Texas prompt-pay requirements simply because a Texas patient receives care from a Texas provider. Texas Department of Insurance

Now flip the facts. An out-of-state patient has a plan issued in Texas and receives care from a Texas provider.

TDI says the Texas prompt-pay rules can apply. In its guidance, TDI specifically says the patient's residence is not the determining factor. Whether the plan was issued in Texas and whether the provider is licensed or otherwise authorized to practice in Texas are important to this particular analysis. Texas Department of Insurance

That gives us the reason this example belongs in Biscuit's story.

We should not replace that shortcut with another one, such as assuming the state where the policy was issued always controls.

Different laws can define their reach differently.

For Texas prompt pay, plan issuance and provider status are important. Another law may use a different set of facts.

Imagine Biscuit works remotely from Austin for a company headquartered in Illinois. Which state's insurance rules govern his health coverage?

It is tempting to pick an address. Biscuit lives in Texas, so Texas. His employer is headquartered in Illinois, so Illinois. Neither is a reliable universal rule.

For a fully insured employer plan, where the policy was issued or delivered may matter. The wording of the particular statute matters. The people, providers, and transactions covered by that law can matter too.

That means the question: "Which state's law applies?"

often needs to become: "Which rule are we trying to apply, and what does that rule say about its reach?"

That is a question a reimbursement team can actually research. And then self-funding changes the analysis again.

Juno lives in Texas too. Now imagine Larkspur Freight is headquartered in Illinois.

Do we simply choose between Texas insurance law and Illinois insurance law? For Juno's plan, there is a more important fact to identify first. Larkspur Freight is a private-sector employer, and its plan is self-funded.

That brings a federal law into our story: the Employee Retirement Income Security Act, or ERISA.

ERISA stands for Employee Retirement Income Security Act. It is a federal law that governs many private-employer benefit plans, including employer health plans.

For this issue, the important distinction is that a private employer's self-funded plan generally is not subject to state insurance mandates in the same way an insured plan is.

For Juno: the fact that Larkspur Freight self-funds its benefits changes the state-law analysis before we start choosing between Texas and another state's insurance rules.

KFF explains that private-employer self-funded plans are exempt from most state insurance laws, including state mandated-benefit requirements and some consumer-protection regulations. KFF

Texas gives members a practical version of the same distinction. For a private-sector employer's self-funded plan like Juno's, TDI directs members to the U.S. Department of Labor's Employee Benefits Security Administration for complaints. Texas Department of Insurance

So if Larkspur Freight were headquartered in Illinois while Juno lived in Texas, we generally would not resolve a state insurance mandate question by choosing whichever address seemed more important.

Her plan's self-funded ERISA structure changes the analysis.

Federal requirements can still apply. The plan's governing terms still matter.

And we should not turn this into "state law can never matter anywhere around a self-funded plan." ERISA preemption has boundaries, and different requirements can interact with self-funded plans in different ways.

You rarely need every fact about a health plan at once. You need the facts that matter to the question in front of you.

Fortunately, patients are not expected to reconstruct federal benefits law from their wallets.

Start with the insurance card. Texas gives us a useful state-specific example:

TDI (Texas Department of Insurance) says cards for fully insured plans it regulates have "TDI" or "DOI" (Department of Insurance) printed on them. Its consumer guidance says a self-funded card can instead indicate that an insurance company administers the plan or use "ASO" (Administrative Services Only). Texas Department of Insurance

Do not assume every state labels cards the same way. Then move to the plan documents. Two acronyms are worth knowing here.

SBC = Summary of Benefits and Coverage

The SBC is a standardized summary of health coverage. Federal rules require group health plans and health insurance issuers to provide it. It includes benefit and cost-sharing information and tells readers that the governing plan or insurance documents contain the actual contractual provisions.

SPD = Summary Plan Description

For an employer plan covered by ERISA, the SPD explains important information about the plan and its administration. When an insurance company is involved in financing or administering the plan, the SPD must describe whether benefits are guaranteed through an insurance contract and what administrative services the company provides.

For this issue: if the insurance card does not settle whether BHC insures the benefits or administers a self-funded employer plan, these documents can provide important clues.

There is no universal SPD field labeled:

You may need to look at the sections describing insurance and administration. Juno also has a much simpler option.

She can call Larkspur Freight's benefits office and ask: "Is our health plan fully insured or self-funded?"

TDI recommends checking plan documents or talking to the employer's benefits administrator when someone cannot determine the type of plan. Texas Department of Insurance

So Juno's practical path looks like this: Insurance card → plan documents → employer benefits office

Let's return to Texas. Texas enacted SB 989, which requires certain health benefit plans to provide biomarker testing coverage when the conditions in the statute are met.

The law identifies the health benefit plans within its scope. The change applies to covered health benefit plans delivered, issued for delivery, or renewed on or after January 1, 2024. Texas Legislature

We are establishing that fact for this example. We are not concluding that the law applies simply because Biscuit lives in Texas.

Now compare Juno. Her Larkspur Freight plan is a private-employer self-funded ERISA plan.

State insurance mandates generally do not apply to that plan in the same way they apply to insured coverage. So our two fictional patients can live in the same state, carry cards showing the same BHC name, use the same BHC PPO network, and still sit under different regulatory structures.

There is one more distinction we need to protect. If the Texas mandate does not require Juno's self-funded plan to provide a benefit, that does not tell us whether Larkspur Freight chose to include the benefit anyway.

The plan can provide benefits that resemble coverage required in the insured market. We have identified whether a particular state mandate reaches the plan. We have not determined whether a particular test is covered for Juno.

That question belongs to another issue.

We started with a card.

Look how much plan identity can sit around it.

Where did the coverage come from? An employer, the individual market, Medicare, Medicaid, or another source?

For employer coverage, is the plan fully insured or self-funded?

What role is the company on the card actually performing?

Is this a PPO, HMO, EPO, POS, or another arrangement?

These are general descriptions. Actual network and referral rules depend on the specific plan - HealthCare.gov

Line of business means the category of coverage the insurer or administrator is handling. Commercial employer coverage, individual coverage, Medicare Advantage, and Medicaid managed care are examples. The same organization can participate in several lines of business, and the rules governing them can differ.

Which federal and state regulatory frameworks could reach this plan and situation?

Does the statute, regulation, contract, or payer policy you found actually apply to this plan?

You do not need all seven pieces to answer every question. You need the pieces that determine the answer to the question in front of you.

If Sage wants to confirm whether Juno's coverage is active, eligibility information is useful. If someone needs to know whether Dr. Singh participates in Juno's network, the network matters. If a team wants to know whether a state insurance mandate governs Juno's plan, the funding arrangement becomes important. If a Texas provider is researching Texas prompt-payment requirements, where the plan was issued and the provider's status become relevant.

Collecting every possible piece of insurance information is not the goal. The useful skill is knowing which piece of plan identity matters to the rule you are trying to apply.

There is one more reason the company name may not finish the job. The same insurance organization can participate in several kinds of health coverage. It might insure one employer's plan. It might administer another employer's self-funded plan. It might offer individual coverage.

The same organization can also participate in Medicare Advantage or Medicaid managed care.

Those arrangements do not share one universal reimbursement rulebook simply because the same company name appears on the card.

So when somebody on a reimbursement team says: "The payer is BHC."

That is useful. The next question may still be: "Which BHC plan?"

That question moves us from the company name toward the rules that actually apply.

Insurance cards should make plan identity easier to understand. Patients should have an easier way to tell whether the company printed across the top is insuring their benefits or administering an employer-funded plan.

Texas's TDI and DOI markers are a useful example of making regulatory status more visible. Better cards would still solve only part of the problem. No single field can tell us whether every reimbursement rule applies. For that, we have to match the rule to the plan.

For billing, laboratory, market access, and RCM teams:

For state-regulated insurance: Start with your state's official insurance department. The National Association of Insurance Commissioners, or NAIC, maintains a directory that links to insurance regulators across the states and U.S. jurisdictions.
Find your insurance department through NAIC

For a private-employer health plan: The U.S. Department of Labor's Employee Benefits Security Administration, or EBSA, provides information about ERISA rights and protections for private-sector employer health plans.
U.S. Department of Labor health plan resources

For certain federal medical-billing protections: The Centers for Medicare & Medicaid Services, or CMS, has consumer resources for federal protections such as the No Surprises Act. Its Help Desk can also direct people toward another resource or agency when appropriate.
CMS medical billing help

A good starting question is still:

"What kind of plan do I have?"

Once you know that, it becomes much easier to figure out which regulator or official source belongs in the conversation.

You do not have to know the answer yourself.

Now you know why the question exists.

There are several branches of this map we intentionally left closed.

We did not get into level-funded arrangements or stop-loss insurance. We did not teach the special rules that can apply to government or church plans. We did not unpack Medicare Advantage or Medicaid managed care in detail.

We also did not cover prior authorization, medical necessity, claims adjudication, rejection versus denial, payment posting, or appeals.

And we have definitely not answered the next dangerous little word:

"Covered."

A plan can say a service is covered and still leave several reimbursement questions unresolved.

That deserves its own issue.

Juno looks at Biscuit's BHC card again, then at her own.

"So we do both have BHC PPO."

"Yep."

"And that doesn't mean our plans work exactly the same way."

"Apparently not."

Nothing printed on either card is wrong.

BHC really does insure Biscuit's plan and administer Juno's plan. Both really do use the BHC PPO network.

Their cards answered useful questions. They simply did not answer every question we asked today. Juno's card did not establish, by itself, that Larkspur Freight carries the financial risk for her benefits.

Biscuit's Texas address did not establish that every Texas insurance rule applies to his coverage. And an employer's headquarters would not give us a universal answer either.

Sometimes funding matters. Sometimes where a policy was issued matters. Sometimes provider status matters. Sometimes federal law changes the state-law analysis.

Which fact matters depends on the rule we are trying to apply. So keep your insurance card handy. It is still one of the most useful starting points you have.

Biscuit and Juno started this morning with two cards that both prominently said BHC PPO. By the end, they had learned that the name on the front was only one piece of their coverage.

Your insurance card can tell you a lot about your health coverage. Sometimes reimbursement depends on what you need to find next.

That's it for this issue. Hit reply. I read everything.

A note on the hypothetical: Biscuit, Juno, Margaret, Sage, BHC, Juniper Lane Design, and Larkspur Freight are fictional. Juno appears only in this issue. The fictional arrangements were created to demonstrate real distinctions among coverage source, funding, administration, network structure, jurisdiction, and rule applicability. For the biomarker example, Biscuit's fictional fully insured BHC plan is expressly assumed to be a health benefit plan subject to the Texas requirement discussed. His residence in Texas is not being used as proof that the statute applies. Juno's fictional Larkspur Freight plan is expressly assumed to be a private-employer self-funded ERISA plan administered by BHC. Neither hypothetical establishes whether any particular healthcare service would actually be covered or reimbursed for either character.

Disclaimer: The content published by preimbursed (the "Newsletter") is provided for general informational and educational purposes only and reflects the opinions and commentary of the author. It does not constitute, and should not be relied upon as, medical, legal, financial, tax, insurance, or other professional advice. No physician-patient, attorney-client, fiduciary, or other professional relationship is created by reading the Newsletter or by corresponding with the author. The Newsletter is not a substitute for individualized advice from a qualified professional. Before making any healthcare, coverage, insurance, financial, or legal decision, you should consult your own physician, attorney, benefits administrator, or other licensed advisor and review your specific plan documents, policies, and applicable law. The author is not responsible for any action taken or not taken in reliance on the content herein, and you assume full responsibility for your use of the information provided. Information in the Newsletter is believed to be accurate as of the date of publication and is drawn from the sources cited. Laws, regulations, coverage rules, corporate ownership, market data, and other facts change frequently and may have changed since publication. Certain statements describe pending, recently enacted, or phased-in legal and regulatory changes whose scope, interpretation, and effective dates may shift. The author makes no representation or warranty, express or implied, regarding the accuracy, completeness, timeliness, or reliability of any content, and disclaims all liability for any errors or omissions to the fullest extent permitted by law. References to any company, organization, product, government program, or individual are made solely for purposes of news reporting, commentary, analysis, and criticism, and do not imply any endorsement, sponsorship, affiliation, or partnership. All trademarks, service marks, and trade names are the property of their respective owners and are used only for identification and descriptive purposes. Where a named party disputes a characterization or finding, the Newsletter notes that dispute. Statements concerning identified companies reflect cited reporting and the author's opinion and analysis of matters of public concern. Certain characters, organizations, and scenarios in the Newsletter, including but not limited to Biscuit, Dr. Singh, and composite payer and provider names, are fictional and used for illustration. Any resemblance to actual persons or entities is coincidental.

Disclosure: The authors are the co-founders of Converus.ai, a company that organizes payer policy information for healthcare providers, and therefore has a commercial interest in the subject matter discussed. References to Converus.ai are made only where relevant and are not paid placements. To the fullest extent permitted by applicable law, the author and preimbursed disclaim all warranties and shall not be liable for any direct, indirect, incidental, consequential, or other damages arising out of or in connection with your use of, or reliance on, the Newsletter.