Key points
- The Employee Benefits Security Administration (EBSA) is the federal agency for private employer health plans. Its benefits advisors can be reached at 1-866-444-3272 or through an online form.
- EBSA is the right office for a self-funded employer plan, where the state insurance department cannot help.
- Agency pages describe EBSA as giving information and guidance, not as deciding your claim. A request for help does not stop your appeal deadline.
If you have health coverage through a private employer, the Employee Benefits Security Administration (EBSA) in the U.S. Department of Labor is the federal agency to contact when the plan breaks the claims rules or you are not sure what the rules are. It is the right office for a self-funded employer plan, where your state insurance department generally cannot help. Call 1-866-444-3272 or use EBSA’s online form. Ask for help in addition to your appeal, not in place of it.
What this means
EBSA enforces the Employee Retirement Income Security Act (ERISA), the federal law that governs most private employer health plans. Its health plans page says EBSA can assist or guide people through the appeals process after a final denial. EBSA’s booklet “Filing a Claim for Your Health Benefits” explains the rules and is published in 13 languages.
EBSA’s own pages describe what its advisors do in terms of answering questions and giving information on possible next steps. Nothing we found promises that EBSA will overturn a denial or order a plan to pay your claim, so treat a call to EBSA as help with the process, not as a way around your appeal. A request for help does not stop your deadline to appeal.
EBSA is for private-sector plans. It is generally not the office for:
- A plan sold by an insurance company that you bought on your own. Contact your state insurance department.
- A state or local government employer plan that the employer funds itself. The Centers for Medicare & Medicaid Services oversees those.
- Federal employee plans. The Office of Personnel Management oversees those.
- Medicare, Medicaid and military coverage.
If you are not sure whether your plan is self-funded or insured, read self-funded or fully insured and who regulates your plan.
What to do
- Finish or keep your appeal moving. Check the date on your notice, which controls. EBSA help does not extend it.
- Write down what you need. For example: the plan has not answered an appeal, the plan has not given you your claim file, or the denial notice left out the reason.
- Gather the papers. The denial letter, your appeal and proof you sent it, any plan reply, and your request for the claim file with its date.
- Contact EBSA. Call 1-866-444-3272, or find the Ask EBSA online form on the Department of Labor’s EBSA pages. The address of the online form has been changing as the Department of Labor moves its website, so search for it from the EBSA home page rather than relying on an old link. The letter asking for Department of Labor help can be pasted into the form.
- Give the facts and the dates. Say which plan it is, who the administrator is and what you have already done.
- Ask what to do next, and write down the answer. Note the advisor’s name, the date and any case number.
- Follow up in writing with the plan. If EBSA gives you a next step, use it and tell the plan you have contacted EBSA.
What the plan may say, and what to say back
“You have no right to those documents.” An administrator of an employer plan must, on written request, provide the latest summary plan description (the booklet describing your plan) and the plan documents. A court may impose a penalty of up to $110 a day on an administrator who fails to mail requested information within 30 days. The penalty is discretionary and only a court awards it. See how to get plan documents.
“EBSA cannot do anything.” EBSA’s advisors provide information and guidance. That is not nothing, but it is not a decision on your claim. Keep appealing.
The rule
Complaints about a private employer plan go to EBSA at 1-866-444-3272 or through its online “Ask EBSA” form. The Department of Labor, through EBSA, is the federal regulator of private employer plans, including those that pay claims themselves. See EBSA’s guide, Filing a Claim for Your Health Benefits and the model notice in title 45 of the Code of Federal Regulations (CFR), section 147.140, which prints the same number.
Watch for
- A moving website. The Department of Labor was in the middle of moving its pages when we checked. The online form could not be opened by our tools, so we cannot describe its fields. Call if the link does not work.
- A complaint is not an appeal. If the plan ignores an appeal, see when the plan goes silent.
- The 30-day penalty is not automatic. It applies to documents ERISA requires an administrator to furnish on written request. Many courts have held that it does not apply to a claim file required only by the claims regulation. We have not confirmed that from the decisions themselves.
- Church and government plans. They may fall outside EBSA. See government and church employer plans.
What next
- External review for self-funded employer plans: the independent step for plans that pay their own claims.
- Asking your employer to overrule a denial: a separate, informal route.
- Free and low-cost help: people who will go through your papers with you.