Government and church employer plans

If you work for a state, a county, a city, a school district or a church, the advice you read for “employer plans” may be wrong for you. Many guides are written for private-sector plans under the Employee Retirement Income Security Act (ERISA), and ERISA does not cover your plan. You are not without rights: a different set of federal and state rules applies. The reference pages for these plans are State or local government employer plan and Church plan.

What this means

ERISA does not cover federal, state, local or school district plans, or church plans that have not chosen ERISA coverage. Three things follow.

• ERISA’s lawsuit rules do not apply. A benefit suit under ERISA is not the route. Because ERISA does not apply, its limits on remedies do not apply either, and state-law claims such as breach of contract or insurance bad faith may be available. Which claims exist depends on your state’s law, and this site has not checked them.
• The Department of Labor is usually not your regulator. The Employee Benefits Security Administration (EBSA) enforces ERISA. For a government plan it is not the agency to call. For a church plan, ask whether the church elected ERISA coverage; if it did, the Department of Labor is.
• The federal public health rules still apply to non-federal government plans. These plans are covered by the Public Health Service Act, including the Affordable Care Act (ACA) claims, appeal and independent review requirements and the No Surprises Act protections against surprise out-of-network bills.

Who oversees you depends on how the plan is funded:

• If your government employer buys insurance, the insurer answers to the state insurance department.
• If the plan is self-funded, the federal Centers for Medicare & Medicaid Services (CMS) oversees non-federal government plans.

What to do

1. Find out exactly what kind of plan you have (you). Ask the plan administrator in writing: is it a government plan or a church plan, is it self-funded or insured, and for a church plan, has it chosen ERISA coverage? Keep the answer. The plan type guide lists other clues.
2. Ask for the plan document and the appeal procedure (you). Read the denial notice and the plan documents for the appeal steps, the deadline and where to send an appeal.
3. File the plan’s appeal inside the deadline on your notice (you). Do not wait to learn which law applies. This site has not confirmed the 180-day federal minimum for these plans separately, so use the date on your notice and plan document. That date controls.
4. Ask for independent review when the plan upholds its denial (you). Self-funded non-federal government plans and insurers use either a state process or a federal one. Your denial notice should tell you which. The process run for the federal Department of Health and Human Services (HHS) is free and has an information line at 1-888-866-6205 (as of November 2026; confirm on the Centers for Medicare & Medicaid Services external review page).
5. Ask whether the plan opted out of any requirement (you). If your denial involves mental health care, this matters, as explained below.
6. Complain to the right agency (you). Insured: your state insurance department. Self-funded government plan: CMS, through its page on self-funded non-federal governmental plans. Church plan: ask the plan which federal rules it follows, and whether a state agency has a role.
7. Ask the employer to look again (you). Your employer sponsors the plan. Ask your employer to overrule explains how to put that request in writing.

The opt-out

A self-funded non-federal government plan may opt out of four federal requirements:

• the newborn and mother hospital stay standards;
• mental health parity;
• coverage of mastectomy reconstruction; and
• coverage of dependent students on medical leave.

No new parity opt-outs have been allowed since 29 December 2022. CMS publishes a list of current opt-out elections. If your plan is self-funded and your denial concerns one of these areas, ask your plan administrator in writing whether it has opted out.

Church plans

A church plan that has not chosen ERISA is outside it. The Internal Revenue Code applies the ACA’s group health plan requirements to group health plans “as if included” in the Code, and a Treasury regulation on internal appeals and external review exists. A church plan’s exemption from ERISA therefore does not by itself remove the ACA appeal and independent review rules.

How those rules are enforced against a given church plan in practice has not been confirmed. If your church plan says it has no independent review, ask it in writing which rule it relies on. Then ask a lawyer or a legal aid office which agency can review that answer.

The rule

ERISA does not apply to a plan established or maintained by a governmental entity, or to a church plan that has not elected ERISA coverage. (ERISA section 4(b), Title 29 of the United States Code (U.S.C.), section 1003(b))

Watch for

• Assuming federal employee rules apply. Federal employees follow a separate federal process. See federal employee plan appeals.
• A union plan. Plans run jointly by unions and employers are not always government plans. Ask the administrator what the plan is.
• A plan that says it is exempt. If a plan says it is exempt from a rule, ask in writing which rule it relies on. The Public Health Service Act applies to non-federal government plans.
• Missing the deadline while you sort it out. File the appeal and ask your questions at the same time.
• State law differences. Rules on lawsuits and time limits differ by state. Talk to a lawyer or a legal aid office before the deadline in your plan document passes.

What next

• Self-funded or fully insured helps you answer the first question.
• Who regulates your plan lists the agencies by plan type.
• The complete employer plan appeal path shows the stages for private employer plans, which you can compare with your own plan document.
• Request external review explains the independent review step.