Appealing a denial on a self-funded employer plan (ERISA)
On a self-funded plan your employer pays the claims and the insurer only administers them. For a PRIVATE employer, ERISA governs, so your state insurance department has no authority. Government, church and federal employee plans are self-funded too, but ERISA does not reach them, and the question below sorts you.
Deadline. At least 180 days from when you RECEIVED the denial, under 29 CFR 2560.503-1(h)(3)(i). Your plan may allow more and may not allow less.
Applies to Self-funded PRIVATE employer and union plans in every state. If your employer is a state or local government, a school district, a church, or a federal civilian agency, your page is Self-funded, non-ERISA. Not sure? Start here sorts it in one question.
Self-funded but not ERISA: government, church, and federal employee plans
Not every self-funded plan is an ERISA plan. State and local government plans, church plans, and federal employee plans are all outside ERISA, so the Department of Labor route does not apply. Government plans can even opt out of some federal requirements, and you can ask to see the election.
Applies to Self-funded plans sponsored by state or local government, churches and church-affiliated employers, and federal CIVILIAN agencies — the FEHB programme. Not private-employer ERISA plans, and not military coverage: TRICARE is a separate system with its own ladder and a shorter clock.
Appealing a denial on a fully insured plan regulated by your state
On a fully insured plan an insurance company carries the financial risk and your state insurance department regulates it. State coverage mandates apply, and after the internal appeal you get an independent external review whose decision binds the insurer. This is the strongest position of any plan type.
Deadline. At least 180 days from RECEIPT of the denial. WHICH RULE gives you that depends on where the policy came from: for employer-sponsored coverage it is the DOL claims regulation, 29 CFR 2560.503-1(h)(3)(i); for a policy you bought yourself it is the HHS side, 45 CFR 147.136, which sets these requirements for health insurance issuers. A plan you bought on the marketplace is NOT an ERISA plan, so citing the DOL rule at your insurer is citing the wrong regulator. External review is four months from the final internal denial either way.
Applies to Individual, small-group, and large-group plans issued by an insurer and regulated by a state insurance department.
Appealing a Medicaid denial for gender-affirming care
Medicaid runs on a different track and a much shorter clock. Managed-care plans give 60 days from the notice date to appeal to the plan; fee-for-service goes to a state fair hearing. You can generally keep benefits during an appeal if you file before the action takes effect. Coverage depends heavily on your state.
Deadline. Shorter than anything else on this site, and there are TWO tracks. If you are in a Medicaid managed-care plan — an MCO, PIHP or PAHP, which is most people — you have 60 CALENDAR DAYS FROM THE DATE ON THE NOTICE to appeal to the plan itself, under 42 CFR 438.402(c)(2)(ii). That is a flat bar, not a range, and it comes BEFORE any state fair hearing. If you are in fee-for-service Medicaid instead, you ask the state directly for a fair hearing, and 42 CFR 431.221(d) gives you a reasonable time not to exceed 90 days from the date the notice was mailed. Either way, to keep care that is already authorised running while you appeal, you generally have to file before the action takes effect — as little as 10 days from the notice. The number on your own notice governs; these are the federal ceilings.
Applies to State Medicaid programs. Coverage and deadlines vary by state, so check your own state's rules.
Marketplace plans and gender-affirming care after the 2026 EHB rule
As of plan year 2026, individual and small-group plans are barred from covering specified sex-trait modification procedures as an essential health benefit. Plans may still cover the care voluntarily, and states may still mandate it. This rule is in effect now and is being litigated, so check the date on anything you read.
Applies to Individual and small-group plans bought on or off the marketplace, whether or not you took a subsidy. On any other kind of coverage, Start here sorts you in one question.
TRICARE: getting gender-affirming care covered by the military health system
TRICARE is not an employer plan and it is not insurance you bought. It is a federal programme written into statute and regulation, so the law that governs it is different from every other page on this site — different rulebook, different appeal ladder, and a deadline that starts on a different day.
Deadline. 90 days from the DATE PRINTED ON THE NOTICE to ask for reconsideration, under 32 CFR 199.10. Read that twice if you have used this site for a commercial plan: those count 180 days from RECEIPT. TRICARE gives you half as long and starts the clock earlier.
Applies to Active duty, Guard and Reserve, retirees, and military family members covered by TRICARE. Not the VA, which is a separate system with separate rules.
VA health care and gender-affirming care: what changed in March 2025
VA health care is not insurance. There is no claim, no insurer and no filing deadline, because the VA provides the care itself. What there is, since 17 March 2025, is a written policy that stopped new gender-affirming care while letting some existing care continue.
Applies to Veterans enrolled in VA health care. Not TRICARE, which covers serving members, retirees and military families and has its own page.
Medicare coverage for gender-affirming care, and how it is decided
Medicare's national policy on this, NCD 140.9, says there is no national rule either way, so the regional contractor that processes your claims decides case by case. Part D covers hormones and Part B covers some care. Procedures classified as facial or cosmetic are denied most often.
Deadline. The windows are NOT uniform and they get SHORTER as you go up, which is the trap if you have read 180 days elsewhere on this site. Read from RECEIPT of each decision: redetermination 120 days (42 CFR 405.942), reconsideration 180 days (405.962), then Administrative Law Judge 60 days (405.1002) and Medicare Appeals Council 60 days (405.1102). All four read directly from the regulation.
Applies to Original Medicare and Medicare Advantage. Advantage plans add their own appeal layer on top of the Medicare rules.
ERISA: what it is, and what it is not
ERISA is the federal law governing most private employer health plans. It is not a coverage rule and it does not say what your plan must pay for. What it does is decide the process, the deadlines, who enforces them, and how much you can recover if you sue.
Applies to Private employer plans, both self-funded and fully insured — ERISA is about who SPONSORS the plan, not who pays the claims. Church and government employer plans are the big exception, and the section below says why that matters.
State coverage mandates, and who they reach
A state mandate only reaches the plans that state regulates, which usually means insurance sold in the state and not a self-funded employer plan. So the first question is not what your state requires, it is whether your state's rule applies to you at all.
Applies to Everyone, but the answer turns entirely on plan type. Work that out first.
Last updated 2026-08-08 · Not legal or medical advice