Coverage type · Job-based plan
State or local government employer plan
Your employer is a state, county, city or school district. Federal employer-plan law does not apply, but Affordable Care Act appeal and independent review rules do, unless the plan is grandfathered. The agency that helps depends on how it is funded.
On this page 7
- Who has this
- People who get health coverage through a state, county, city, town or school district employer. Federal employees have a different program; see the page for Federal Employees Health Benefits plans.
- Who regulates it
- If insured: your state insurance department. If self-funded: the federal Centers for Medicare & Medicaid Services (CMS), part of the Department of Health and Human Services (HHS). The Department of Labor generally does not regulate governmental plans.
- Can your state help?
- Partly. Yes if the plan is fully insured, because the state regulates the insurer. Generally no if the plan is self-funded, where the federal government (CMS) is the regulator. Your state may also have its own rules for government employee plans; we could not confirm those rules, so ask your benefits office. Find your state.
How to tell this is your coverage
- Your employer is a state, local or school district government. That alone tells you the Employee Retirement Income Security Act (ERISA) does not cover the plan. It does not yet tell you whether the plan is insured or self-funded.
- Ask your human resources or benefits office: Is our plan self-funded or fully insured? Who is the insurer, and who is only the claims administrator?
- Ask for the plan document and the summary of benefits in writing, and read what they say about how claims are paid and about appeals.
- Look at the denial notice. A notice that does not mention the right to sue under ERISA fits a government plan, but treat that as a clue, not proof.
- Once you know, the regulator follows: an insured plan is regulated by the state insurance department; a self-funded non-federal governmental plan is regulated by the federal Centers for Medicare & Medicaid Services (CMS).
The appeal steps, in order
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First appeal to the plan
Official name: Internal appeal (an appeal of an adverse benefit determination)
- Who decides
- Your plan or its insurer or claims administrator. A governmental plan must follow the Affordable Care Act (ACA) claims and appeals rules, unless it is grandfathered. A grandfathered plan (in place on 23 March 2010 and not changed in disqualifying ways) is exempt from general external review except for surprise-billing denials; see the page for grandfathered plans.
- Your deadline
- The federal minimum for group health plans is 180 days after you receive the denial notice. We could confirm that figure for employer group plans in general, but not separately for your government plan. Your denial notice and plan document state the deadline that applies to you. 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.
- If you lose, or hear nothing
- If the plan upholds the denial and has a second level, file it. Otherwise request independent external review.
- The rule
- 45 CFR 146.180, non-federal governmental plans and the Public Health Service Act
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Independent external review
Official name: External review by an independent review organization (IRO)
- Who decides
- If your plan is insured, the state external review process (an independent review organization assigned by the state), unless your state has no qualifying process. If your plan is self-funded and your state's process does not meet the federal standards, the plan chooses between a private accredited independent review organization process and the federal government's own process, which is free and run for HHS by a contractor. Ask the plan which one applies to you.
- Your deadline
- At least 4 months after you receive the denial notice (the final internal denial, if you appealed first). Check the date on your notice, which controls.
- Their deadline
- A standard decision is due within 45 days after the independent reviewer receives your request. An urgent decision is due as fast as your medical situation requires and 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. For the federal government's process, the information line is 1-888-866-6205 (as of November 2026; confirm on the Centers for Medicare & Medicaid Services external review page) and the process is free. Denials involving medical judgment, No Surprises Act protections or a cancellation of coverage (rescission) qualify; a denial because you are not eligible for the plan does not.
- Form
- HealthCare.gov, external review
- If you lose, or hear nothing
- If the reviewer overturns the denial, the plan must provide coverage or payment immediately. If not, complain to the regulator and talk to a lawyer.
- The rule
- 45 CFR 147.136(c) and (d), external review for non-federal governmental plans
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Complaint to the regulator
Official name: Regulator complaint
- Who decides
- For an insured plan, your state insurance department. For a self-funded non-federal governmental plan, the Centers for Medicare & Medicaid Services (CMS). We did not confirm a CMS consumer phone number or complaint form, so start from the CMS page on these plans.
- Your deadline
- We could not confirm a deadline for this step. A complaint does not stop your appeal or external review deadlines, so keep them running. Check the date on your notice, which controls.
- Their deadline
- Set by the agency; we did not confirm a response time.
- What to send
- A short written complaint with your plan name, member number, the denial notice and the dates of every appeal.
- Form
- CMS, self-funded non-federal governmental plans
- If you lose, or hear nothing
- Use the agency's answer in your external review request or when you talk to a lawyer.
- The rule
- 42 U.S.C. 300gg-22, enforcement of Public Health Service Act requirements
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Lawsuit in court
Official name: State-law claim (ERISA does not apply)
- Who decides
- A judge. ERISA does not cover governmental plans, so its lawsuit rules and its limits on remedies do not apply. 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 state's law and, possibly, by your plan document. 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 disputes in your state can tell you which claims you have.
- 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 for an urgent appeal. For group health plans the decision is due as soon as possible and no later than 72 hours. If a doctor who knows your condition says the claim is urgent, the plan must treat it as urgent. You can ask for an urgent independent review at the same time.
Free help for this coverage
- Your state insurance department
If your plan is insured, it takes complaints about the insurer. Find yours in the National Association of Insurance Commissioners directory.
- 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.
- Free legal aid
Legal aid offices and your state bar association can point you to a lawyer who handles health insurance disputes.
Who this covers
This page is for you if you are covered through a state, county, city, town or school district employer. The federal law for private employer plans, the Employee Retirement Income Security Act (ERISA), does not cover these plans. The Public Health Service Act does, and through it the Affordable Care Act (ACA) rules on appeals, independent review and the No Surprises Act. A grandfathered plan is exempt from the appeal and general external review rules; see grandfathered plans.
How to tell this is your coverage
Your employer’s type answers most of it. The open question is whether the plan is insured or self-funded, because that decides whether your state insurance department or the federal government is the regulator. Ask your benefits office in writing and keep the answer.
What does not apply to you
ERISA’s lawsuit rules and its limits on remedies do not apply, and the Department of Labor’s Employee Benefits Security Administration generally does not regulate your plan. A self-funded government plan may opt out of four federal requirements: newborn and mother hospital stay standards, mental health parity, mastectomy reconstruction coverage, and coverage of dependent students on medical leave. No new parity opt-outs have been allowed since 29 December 2022. The Centers for Medicare & Medicaid Services keeps a list of plans that have opted out, linked in the sources below. Check the list for your plan before you rely on a parity argument.
Where people go wrong
- Writing to the Department of Labor about a government plan. Start with the plan, then the regulator named above.
- Assuming your state insurance department can help with a self-funded government plan. It usually cannot.
- Assuming the 180-day appeal deadline applies to you without reading your notice. Use the date on your notice.
- Mixing this up with federal employee coverage. See Federal Employees Health Benefits plans.
Sources
- 45 CFR 146.180, treatment of non-federal governmental plans
- 45 CFR 147.136, internal claims and appeals and external review for non-grandfathered coverage
- Self-funded non-federal governmental plans
- Forms, reports and other resources, including the list of governmental plan opt-out elections
- ERISA section 4(b), 29 U.S.C. 1003
- 42 U.S.C. 300gg-22, enforcement
- Which states use which external review process
- HHS-administered federal external review process
- HealthCare.gov, external review
- State insurance departments directory
- Consumer Assistance Program
- Patient Advocate Foundation case management