Coverage type · Job-based plan
Church plan
A health plan run by a church is usually outside the federal employer-plan law unless the church chose coverage. Federal appeal rules may still apply through the tax code, but who enforces them is less clear. Read your notice closely.
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- Who has this
- People who get health coverage through a church plan. The plan may be paid for by the church itself or insured through an insurance company.
- Who regulates it
- We could not confirm this. A church plan that has not chosen ERISA is outside ERISA. The Internal Revenue Code and a Treasury regulation apply the Affordable Care Act appeal and external review rules to group health plans, but how they are enforced against a particular church plan was not confirmed. If an insurer issues the policy, your state insurance department regulates the insurer.
- Can your state help?
- Partly. Yes if an insurance company issues the policy, because the state regulates the insurer. If the church pays claims itself, state insurance law may not reach the plan, and we did not confirm who enforces the federal rules. Ask the state insurance department whether it can take your complaint. Find your state.
How to tell this is your coverage
- Ask the plan administrator or the church's benefits office: Is this a church plan? Did the church choose to be covered by the Employee Retirement Income Security Act (ERISA)? Is the plan self-funded or insured?
- Read the summary plan description or plan document. A church plan that chose ERISA coverage will say so and will follow the employer-plan rules; see the pages for self-funded or fully insured employer plans.
- Read the denial notice. If it tells you about a right to sue under ERISA, treat your plan as an ERISA plan. If it does not mention ERISA, ask the plan in writing which law governs it.
- Ask who the claims are paid by. If an insurance company issues a policy, your state insurance department regulates that insurer.
The appeal steps, in order
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First appeal to the plan
Official name: Internal appeal
- Who decides
- The plan or its claims administrator. If the church chose ERISA coverage, the ERISA claims rules apply, including a fresh reviewer who did not make the first decision.
- Your deadline
- The federal minimum for group health plans is 180 days after you receive the denial notice. We could confirm that a matching Treasury rule exists for church plans, but not how it is applied to yours. Use the deadline in your denial notice, and appeal as early as you can. Check the date on your notice, which controls.
- Their deadline
- For group health plans in general: urgent care no later than 72 hours after your appeal is received; care you need approved first, 30 days; care you already received, 60 days; if the plan has two levels, each level gets half of the 30 or 60 days (15 or 30 days), and an urgent appeal is still decided within 72 hours. Check the date on your notice, which controls.
- What to send
- A written appeal naming the claim and the denial, with your records, your doctor's letter and your reasons. Ask first for your claim file and the plan document.
- If you lose, or hear nothing
- If the plan upholds the denial, ask in writing whether it offers independent external review and how to request it.
- The rule
- 26 CFR 54.9815-2719, internal claims and appeals and external review (Treasury)
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Independent external review
Official name: External review by an independent review organization (IRO)
- Who decides
- An independent review organization (IRO). We could confirm that the tax code applies the group-plan rules to church plans and that a matching Treasury regulation exists, but not which process, state or federal, your plan uses. Ask the plan which one applies. Your denial notice should tell you how to start external review; if it does not, ask the plan in writing.
- Your deadline
- For group health plans in general, at least 4 months after you receive the denial notice (the final internal denial, if you appealed first). Confirm this with your plan. Check the date on your notice, which controls.
- Their deadline
- For group health plans in general, a standard decision is due within 45 days after the independent reviewer receives your request, and an urgent decision no later than 72 hours.
- What to send
- Follow the instructions in your final denial notice. Include the denial notice, your records and your doctor's letter.
- If you lose, or hear nothing
- If the plan will not give you external review, tell your state insurance department (if insured) and ask a lawyer whether the plan broke the federal rules.
- The rule
- 26 U.S.C. 9815, group health plan requirements in the Internal Revenue Code
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Complaint to the state insurance department
Official name: Regulator complaint (insured plans)
- Who decides
- Your state insurance department, if an insurance company issues the policy. It regulates the insurer, not the church. If the church pays claims itself, we did not find a clear federal agency to complain to; the Department of Labor's help line (1-866-444-3272) may be able to tell you whether it can help.
- Your deadline
- We could not confirm a deadline for this step. A complaint does not stop your appeal deadlines. Check the date on your notice, which controls.
- Their deadline
- Set by your state.
- What to send
- A short written complaint with your policy number, the denial notice and the dates of every appeal.
- Form
- Find your state insurance department (National Association of Insurance Commissioners)
- If you lose, or hear nothing
- Use what the department tells you in your next step.
- The rule
- 42 U.S.C. 300gg-22, state and federal enforcement
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Lawsuit in court
Official name: ERISA suit if the church chose ERISA; otherwise a state-law claim
- Who decides
- A judge. If the church chose ERISA coverage, you can sue to recover benefits under ERISA section 502(a). If it did not, ERISA does not apply, and state-law claims such as breach of contract may be available. Which claims exist depends on your state's law, and we did not check it.
- Your deadline
- Set by your plan document or your state's law. Ask a lawyer early. Check the date on your notice, which controls.
- Their deadline
- Set by the court.
- What to send
- A lawyer files the claim. Keep your whole appeal record.
- If you lose, or hear nothing
- Free legal aid or a lawyer who handles insurance or benefit disputes can tell you which rules apply to your plan.
- The rule
- ERISA section 4(b), 29 U.S.C. 1003
If waiting could harm your health
If waiting could seriously harm your health, ask the plan for an urgent appeal in writing and by phone, and have your doctor say in writing that the case is urgent. For group health plans in general the decision is due no later than 72 hours. We could not confirm how this is enforced against church plans, so also ask whether you can start an urgent external review at the same time.
Free help for this coverage
- Your state insurance department
If an insurer issues your policy, it takes complaints about the insurer. Find yours in the National Association of Insurance Commissioners directory.
- Department of Labor benefits advisors
Free help at 1-866-444-3272 for questions about employer plans. Ask whether your church plan is one they can help with.
- Your state Consumer Assistance Program
The Centers for Medicare & Medicaid Services list gives contacts by state. It says no program receives federal grant money as of its September 2024 update, so confirm your state's listing is current.
- Patient Advocate Foundation case management
Free one-on-one help for patients who qualify, by phone at 1-800-532-5274, Monday to Friday, 8:30 a.m. to 5:00 p.m. Eastern (hours as listed in November 2026). It has limits on how many people it can take each day.
Who this covers
This page is for you if your coverage comes from a church plan. The Employee Retirement Income Security Act (ERISA), the federal law for private employer plans, does not cover a church plan unless the church chose to be covered. If the church did choose ERISA, use the pages for self-funded or fully insured employer plans, whichever fits.
How to tell this is your coverage
Ask the plan in writing whether it is a church plan, whether the church chose ERISA coverage, and whether it is insured or self-funded. The answer decides which rules and which agency apply. Keep the reply.
What does not apply to you
If the church did not choose ERISA, ERISA’s appeal-and-lawsuit rules do not apply, and neither do its limits on remedies. That can leave room for state-law claims. A church plan being outside ERISA does not by itself remove the federal appeal and external review rules, which the tax code applies to group health plans. We did not confirm how those rules are enforced against a particular church plan.
Where people go wrong
- Assuming a church plan has no appeal rights. Federal rules may still apply, and the plan documents give you steps.
- Assuming the state insurance department can help with a plan the church funds itself. It may not be able to.
- Waiting for an answer about which law applies. Appeal inside the deadline on your notice while you ask.
Sources
- 26 U.S.C. 9815, additional market reforms
- 26 CFR 54.9815-2719, internal claims and appeals and external review
- ERISA section 4(b), 29 U.S.C. 1003
- 42 U.S.C. 300gg-22, enforcement
- 29 CFR 2560.503-1, claims procedure
- Filing a Claim for Your Health Benefits
- Ask EBSA, request help from a benefits advisor
- State insurance departments directory
- Consumer Assistance Program
- Patient Advocate Foundation case management