What to do
Confirm the plan really is self-funded
Ask HR or benefits two questions: is this plan self-funded or fully insured, and is the employer a private company? A city, school district, public university, or church is self-funded but not ERISA, and belongs on the non-ERISA page instead.
Request the Summary Plan Description and the full plan document
You are entitled to both in writing. The SPD is the readable summary; the plan document is what actually governs and wins when the two disagree.
Find the exclusion or the medical-necessity criteria being applied
A denial rests on either a written exclusion or a clinical criterion. Which one it is changes the entire argument, so read the denial letter against the plan document before you write anything.
File the internal appeal inside the plan's deadline
The federal floor is at least 180 days from when you received the notice. Your plan document may allow more. Count from the printed date and you have a margin either way.
Request the parity comparative analysis if a mental-health criterion is involved
Plans must produce a comparative analysis for non-quantitative treatment limitations on request. The obligation survived the 2024 rule being paused.
Escalate to the Department of Labor, not the state
Self-funded plans answer to the Employee Benefits Security Administration. A complaint to a state insurance commissioner will be returned for lack of jurisdiction.
Why this fork matters more than anything else on this site
Most advice about appealing an insurance denial assumes a state regulator is standing behind you. On a self-funded plan, none of it applies. The state insurance department cannot help, state coverage mandates do not reach the plan, and an external review may be voluntary rather than guaranteed.
People spend months arguing with the wrong regulator because nobody told them their plan type. That is the single most common avoidable delay in this whole process.
What still helps you
ERISA gives you real rights: written reasons for the denial, access to the documents the decision relied on, a full and fair review, and a right to sue after you have exhausted the internal process.
- The plan must give you, free of charge, every document and internal rule it used to decide.
- The reviewer on appeal must not be the person who made the original decision, or their subordinate.
- If a clinical judgment is involved, the plan must consult a professional with appropriate expertise.
- If the plan misses its own deadlines, you may be able to treat the internal process as exhausted and move on.
Common questions
- How do I know if my plan is self-funded?
- Ask your employer's HR or benefits contact directly. Self-funded plans are usually administered by a familiar insurer name, so the card looks identical to a fully insured plan. The Summary Plan Description will also say.
- Does my state's gender-affirming care mandate apply?
- No. State insurance mandates reach insurers, and a self-funded plan is not insured. Colorado's benchmark, for example, does not bind a self-funded employer plan.
- Can I still get an external review?
- Often yes, but the route differs from a state-regulated plan. Check the denial letter for external-review instructions and confirm with the plan administrator.
Better covered elsewhere
- A4TE Trans Health Project — insurance tutorial and appeal templates
Deeper legal detail. Some state-level resources there are marked Archived.
Where to go next
Sources for the legal points on this page
- Mental-health parity: the 2024 rule is paused, the older duties are not
Federal — group health plans and issuers · effective non-enforcement announced 2025-05-15
29 CFR 2590.712 and 2590.712-1 — current text still carries the 2024 rule (definitions keyed to 22 November 2024), so the rule was not rescinded. The May 2025 non-enforcement policy is sub-regulatory and was NOT located in the Federal Register, so it remains unverified
Status: contested · source-checked 2026-08-06 · primary source verified: 2026-08-06 (partial — regulation text verified, non-enforcement policy not)