Key points
- Different agencies oversee different plans. Calling the wrong one wastes time you may not have.
- State insurance departments cover insurance companies and their policies. They generally do not cover self-funded employer plans, Medicare or Medicaid.
- Self-funded employer plans go to the federal Employee Benefits Security Administration.
- A regulator can look into a complaint. It does not replace your appeal deadline.
The agency that can act on a complaint depends on your kind of plan. Call the wrong one and you may be sent away after waiting. Find your plan type first, then use the list below.
What this means
A regulator checks that a plan follows the law. Regulators differ by plan type, and not every plan has one close to home.
| Your coverage | Who oversees it | Where help starts |
|---|---|---|
| Job-based, fully insured (employer buys a policy) | The state insurance department for the insurer and policy. The Department of Labor also oversees private employer plans. | State insurance department; Employee Benefits Security Administration (EBSA), 1-866-444-3272 |
| Job-based, self-funded (employer pays claims) | EBSA. State insurance laws generally cannot be applied. | EBSA, 1-866-444-3272 |
| Self-funded plan of a state or local government | Federal government, through the Centers for Medicare & Medicaid Services (CMS) | CMS page on self-funded government plans |
| Church plan | Federal appeal rules can still apply through the tax code; how they are enforced against a particular plan is not confirmed | Ask your plan which rules it follows |
| Marketplace or individual plan | State insurance department is the primary regulator | State insurance department; state consumer assistance program |
| Federal Employees Health Benefits (FEHB) plan | Office of Personnel Management (OPM) | The plan’s brochure, then OPM |
| Original Medicare, Medicare Advantage, Part D | CMS | 1-800-MEDICARE, 1-800-633-4227; State Health Insurance Assistance Program (SHIP) for free counseling |
| Medigap | The state, which regulates the policies | State insurance department |
| Medicaid and the Children’s Health Insurance Program | The state agency, under federal rules | The notice’s hearing or review instructions |
| TRICARE, Veterans Affairs, Indian Health Service | Their own programs | The program’s appeal instructions |
A fully insured employer plan is covered by both the federal law for employer plans (the Employee Retirement Income Security Act, or ERISA) and the state insurance law that binds its insurer. A self-funded ERISA plan is not treated as an insurer, so a state generally cannot apply its insurance laws to it.
What to do
- Find your plan type. Use the coverage type finder or read how to find out what kind of plan you have.
- If you have a job-based plan, find out whether it is self-funded. See self-funded or fully insured.
- Look up the right agency. Your state’s page lists its regulator and complaint form. Examples: Texas (the Texas Department of Insurance says it regulates the fully insured plans that cover about 20% of Texans), and California (two regulators, depending on the plan).
- File your appeal first or at the same time. A complaint does not stop your appeal clock (check the date on your notice, which controls).
- Use the regulator complaint builder and the call script for the regulator to prepare.
- Write down the name of who you spoke to, the date and a reference number. Use your call log.
What the plan may say, and what to say back
“Our regulator is the Department of Labor.” Ask: “So the plan is self-funded? Can you confirm that in writing?”
“The state cannot help you with this plan.” Ask which agency can, and ask for its name and phone number. Then call that agency.
The rule
Private employer plans are overseen by the Department of Labor’s Employee Benefits Security Administration; insurance companies and their policies by the state insurance department, with the federal government stepping in only if a state fails to substantially enforce federal requirements; self-funded non-federal governmental plans by the federal government through CMS; and Federal Employees Health Benefits plans by the Office of Personnel Management. Source: Title 42, United States Code (U.S.C.), section 300gg-22(a) and the Department of Labor’s Filing a Claim for Your Health Benefits.
Watch for
- Church plans. An exemption from ERISA does not by itself remove the federal appeal and external review rules, but we could not confirm how they are enforced against a particular church plan. Ask your plan which rules it follows.
- Medicaid. The state agency runs the hearing system. See Medicaid appeals and fair hearings.
- Free counselors. For Medicare, State Health Insurance Assistance Programs give free one-on-one counseling and are not connected to any insurance company. See Medicare counseling.
- A complaint is not a ruling in your favor. A regulator may look into the plan’s conduct. It does not decide your medical question the way an independent reviewer does.
What next
- Go further on regulators: complain to your state insurance department or get help from the Department of Labor.
- Learn the difference between a complaint and an appeal: appeal, complaint, grievance and external review.
- Find a person to help: state consumer advocates.
- Go to the topic page, find out what kind of coverage you have.