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.
Every insurance-rights card here starts with the same question: does an insurance company pay the claims (Washington’s rules apply), or does the employer pay them itself and use an insurer only to process them (federal rules generally apply)? The insurer’s name on the card does not answer it. Ask HR once, in writing, and keep the answer with the insurance card.
What each answer changes
- If the company buys insurance from an insurance company (“fully insured”), Washington’s rules on approval deadlines, outside review, copay-card counting and oral chemo parity apply to the plan.
- If the company pays the medical bills itself (“self-funded”), federal rules generally apply instead. Surprise-bill protection, the continued-care right after a network termination, the federal appeal rules and the clinical-trial rule still bind those plans.
- Plans from a Washington state agency, public college, school district or charter school (PEBB or SEBB), and government, federal or church employers, follow their own routes.
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
Funding is the first clue, not the whole answer: public-employer plans, grandfathered plans and some Washington provider duties need separate checking. Washington’s insurance commissioner consumer line (800-562-6900) can help identify the type of coverage; for private-employer plans the federal benefits agency line is 866-444-3272.
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
How this works
An insurer's logo on the card does not answer this question: the company may only administer a plan funded by the employer.
Ask the benefits office for the plan's funding type and Summary Plan Description. Public-employer, federal, school and church plans can follow different rules; do not assume they work exactly like a private employer plan.
You do not need to solve this before asking for help with a bill or urgent treatment problem. The benefits office or insurance regulator can help identify the correct route.
- Ask HR: 'Is this plan fully insured or self-funded, and who handles complaints and external appeals?'
Before you start
- State residence alone does not prove that every Washington insurance rule applies.
- Save the written answer with your insurance documents.
State residence alone does not prove that every Washington insurance rule applies.
Save the written answer with your insurance documents.
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