ERISA vs state-regulated health plans: why it matters
Who can help you after a denial depends on how your plan is set up. This is one of the most confusing parts, and the main reason a state insurance department sometimes says "we can't help."
| Plan type | Who regulates it (generally) | Where to turn |
|---|---|---|
| Individual or Marketplace plan (you bought it) | State insurance department, plus federal ACA rules | Internal appeal, then external review (state or federal process), and a state insurance department complaint. |
| Employer plan, fully insured (employer buys a policy from an insurer) | Federal ERISA claim rules for private-sector plans, and the state regulates the insurer | Internal appeal under ERISA rules; external review follows the state or federal process that applies to the insurer; the state department can usually take complaints about the insurer. |
| Employer plan, self-funded (the employer pays claims; an insurer or administrator may only run it) | ERISA and the U.S. Department of Labor, not the state insurance department | Internal appeal under ERISA rules; external review follows the federal process for the plan; contact EBSA at askebsa.dol.gov or 1-866-444-3272. |
| Government or church plans | ERISA does not cover some of these plans | Check the plan documents; self-funded state and local government plans may use a federal external review process. |
| Medicare / Medicaid | Federal and state programs | See the Medicare and Medicaid basics. |
How to find out which you have
- Ask your employer's benefits office: "Is our plan fully insured or self-funded?"
- Look in the Summary Plan Description (SPD), which also explains how to file a claim. You can request it in writing from the plan administrator.
- State departments say this on their own pages: Alabama's says that if a plan is self-funded, your employer administers it; Kansas lists self-funded plans as outside its jurisdiction.
Both groups still get appeal rights
The Labor Department says ERISA plans must give at least 180 days to appeal a denial and must follow set decision timelines, and that non-grandfathered plans must provide external review, with the process depending on whether the plan is self-funded or insured.
Plan classifications have exceptions. If you are unsure, call the plan, read your SPD, or contact EBSA or your state's consumer assistance program. A lawyer can tell you which rules apply.
Sources
- U.S. Department of Labor (EBSA): Filing a Claim for Your Health or Disability Benefits, last verified 2026-10-17
- U.S. Department of Labor (EBSA): Filing a Claim for Your Health Benefits, last verified 2026-10-17
- Alabama DOI: File a complaint, last verified 2026-10-17
- Kansas Insurance Department: Complaint Index, 2025 Report (PDF), last verified 2026-10-17
- HealthCare.gov: External review, last verified 2026-10-17
- CMS: Coverage Appeals Job Aid, last verified 2026-10-17
Page last reviewed October 17, 2026. Rules change; confirm with your notice, plan documents or the agency pages above.