Self-funded employer plans: which rules apply to your appeal?

Your appeal rights depend on who provides your coverage. The same basic federal rules cover most job-based and individual plans, but who runs the outside (external) review, and who you complain to, can differ.

Checked against official sources: October 30, 2026.

Insured plans and self-funded plans

  • If your plan is health insurance bought from an insurance company (on your own, through the Marketplace, or through an employer that buys insurance), your state's insurance regulator oversees it. Your state's external review process applies if it meets federal standards.

    Law: 45 CFR 147.136(c)(1)(i)

  • Many large employers pay claims themselves instead of buying insurance. This is called a self-insured (self-funded) plan. Most state insurance laws do not apply to these plans. They must still offer an internal appeal and an external review under federal rules, usually through independent review organizations the plan contracts with.

    Law: 29 CFR 2590.715-2719(c)(1)(ii), (d); HealthCare.gov glossary: self-insured plan

  • If your state lets self-insured plans use its external review program, the plan may choose the state process or the federal one.

    Law: 29 CFR 2590.715-2719(c)(1)(ii)

How to tell which one you have

  • To find out if your employer plan is self-insured, check your plan booklet (summary plan description) or ask your HR office or plan administrator. Your denial notice must also tell you who handles external review.

Law: HealthCare.gov, External Review; HealthCare.gov glossary

Government plans and other coverage

  • Health plans of state and local governments that are self-insured may use the external review process run by the U.S. Department of Health and Human Services (HHS).

    Law: 45 CFR 147.136(d)(4)

  • Medicaid works differently. You appeal a Medicaid denial, cut or end of coverage by asking for a state fair hearing. If you are in a Medicaid managed care plan, you usually appeal to the plan first.

    Law: 42 CFR 431.220-431.221; 42 CFR 438.402, 438.408

  • Decisions by the Health Insurance Marketplace about whether you can buy a plan or get financial help are appealed to the Marketplace, not to the insurance company. A refused claim from a Marketplace plan is appealed to the insurance company.

    Law: 45 CFR 155.505(b); HealthCare.gov, What can I appeal?

  • Some old plans (grandfathered plans) do not have to follow most of these appeal rules. They still must offer external review for surprise billing protections.

    Law: 45 CFR 147.136(a)(1)(ii)

Court after the appeals (ERISA plans)

  • For an employer plan covered by ERISA, the final denial notice must tell you about your right to file a lawsuit under section 502(a) of ERISA. Plans may not require more than two appeal levels before you can sue. Court deadlines can be short, so free legal help can explain your options.

Law: 29 CFR 2560.503-1(c)(2), (j)(4)(i); 29 U.S.C. 1132(a)

Plan documents you can request

  • For an employer plan covered by ERISA, you can ask the plan administrator in writing for the plan documents, such as the summary plan description. The administrator may charge a reasonable copying fee. If it does not send them within 30 days, a court may order it to pay you up to $110 a day.

    Law: 29 U.S.C. 1024(b)(4); 29 U.S.C. 1132(c)(1); 29 CFR 2575.502c-1

  • During the appeal, the plan must give you, free and in time to respond, any new evidence or new reason it plans to use against you.

    Law: 45 CFR 147.136(b)(2)(ii)(C)

Before you act

Ask your employer's benefits office whether the plan is insured or self-funded and who the claims administrator is. Keep the answer in writing.

Quick answers

How do I know if my plan is self-funded?

To find out if your employer plan is self-insured, check your plan booklet (summary plan description) or ask your HR office or plan administrator. Your denial notice must also tell you who handles external review.

Does my state's insurance department cover my plan?

Many large employers pay claims themselves instead of buying insurance. This is called a self-insured (self-funded) plan. Most state insurance laws do not apply to these plans.

Free help

Free help can look at your denial and your letters. Consumer assistance programs, legal aid groups and state insurance departments do not charge for this.

Free calculator and letters

Appeal deadline calculator

Letter: appeal to your plan

Letter: ask for external review

Letter: Medicaid fair hearing request

Sources