Federal, exists in every state
Find out which insurance rules apply to your work plan
Whether the employer buys insurance from an insurance company or pays the medical bills itself decides which appeal rules and which agency can help.
What it is
Whether the employer buys insurance from an insurance company or pays the medical bills itself decides which appeal rules and which agency can help.
An insurance company may pay your claims, or your employer may pay them directly. That difference helps identify which state and federal protections apply. The insurer’s name on the card does not answer it; HR can provide the plan’s funding arrangement and booklet.
What each answer changes
- For fully insured plans subject to Pennsylvania law, state prior-approval deadlines, external review and oral chemotherapy parity can apply. The specific plan and service matter.
- For a private employer’s self-funded plan, federal law generally supplies the main protections. The surprise-billing, continuity, appeal and clinical-trial rules depend on the plan and service, including grandfathered status. Government and church plans need separate classification.
- Government, federal and church employer plans can follow different rules; HR can identify the employer’s legal type and the plan’s regulator.
What you get
- A written answer on how the plan is funded, the plan name and administrator, and the plan booklet, which is what a social worker or benefits counselor needs to work out which rules apply.
- Knowing which agency to call when a treatment is denied or delayed.
If you decide to apply
- If you do not yet know, ask HR by email: "Is our medical plan fully insured or self-funded? In other words, who pays covered claims, the insurance company or our employer? Could you send me the plan administrator's answer and the plan booklet?" If you already know, keep the plan booklet and the administrator's name with the insurance card.
- Keep the answer with the insurance card.
HR or the benefits office · Official page ↗
Good to know
Public-employer, federal and church plans can follow different rules. The plan booklet and employer type help identify the right agency.
Official sources
“Which protections and appeal route apply to our work plan, given how it is funded, and who do we call if a treatment is denied?”
Why I’m asking: The card’s company name does not tell us who funds the plan or which rules protect us.
More background and detailed requirements
Additional program information and published rules
Who does what
The three parts, side by side. The agency decides; nobody on this page does.
You
If the funding type is unknown, ask HR whether the employer pays claims itself or an insurer carries the risk.
Your social worker
Explains which state items depend on the answer.
The care team
Records and letters when the application asks for them.
- Who decides
- Nobody decides. It is a fact about the plan that HR can state
- Ask HR
- “Who funds our plan, is it a federal, government or church plan, and which appeal process and treatment protections apply? Can you send that in writing?”
How to apply
First step: Ask HR: “Who funds this plan, is it a federal, government or church plan, and which appeal process applies? Please send the current plan document.”
- Email HR the funding question.
- Ask for the Summary Plan Description.
Where it starts: One email to HR. The Summary Plan Description
What to gather
- The insurance card
- The Summary Plan Description
How long: One reply from human resources.
What a yes looks like
A written answer. Enter it above and the appeal and mandate items update.
What a no looks like, and the next move
human resources does not know: ask the benefits administrator named on the card, or read the funding section of the Summary Plan Description.
Watch out
- The logo on the card does not tell you who funds the plan. Ask the benefits office for the funding type and current appeal document.
- Federal employees use the carrier’s FEHB reconsideration route and then OPM; state external review is not the FEHB route.
- State and local-government or church plans are not ordinary private-employer ERISA plans. Public plans can carry state-law or contractual protections even when employer-funded.
The numbers and the rules
The arcane layer, kept on purpose. Checked September 10, 2026.
What it is worth
The right appeal option and the right list of protections.
Legal protection: Right to the Summary Plan Description and plan document in writing · Correct state-versus-federal routing
What it costs the family: No fee.
The eligibility facts, as published
- Employer plan required
- yes
Decisions this site cannot make: Plan funding status
Expect friction on: HR terminology
The trap: Treating a public or church employer’s self-funded plan as an ordinary private ERISA plan. Ask the benefits office for the current appeal document.
What changes by state: Which mandates and which external-review option apply to a fully insured plan.
Where I read this
- ERISA — U.S. Department of Labor, read August 27, 2026