The Employee Retirement Income Security Act of 1974 (ERISA), is a federal statute that delineates minimum standards for the administration of benefits and is regulated by the office of Employee Benefit Security Administration
(EBSA) within the Department of Labor. Plans that are self-insured are regulated by ERISA. With these plans, the employer is responsible for paying the employees' health claims and the health plan is only responsible for administrative functions.
In a fully-insured plan, the employer pays a per-employee premium to an insurance company, and the insurance company assumes the risk of providing health coverage and claims payment. These types of plans can be easily identified as "TDI" or "DOI" will be printed on the insurance cards. Fully-insured plans are regulated by the Texas Department of Insurance (TDI)
and are subject to Texas Prompt Pay Rules
, also known as Senate Bill 418.
Instructions on filing a complaint can be found on the TDI complaint page
In a self-insured plan, the employer acts as its own insurer and assumes financial risk for claims payment. Self-insured plans often contract with an insurance company or other third party to administer the plan, but the employer bears the risk associated with offering health benefits. Since self insured plans are not regulated by TDI the plans are not subjected to Texas Prompt Pay Rules.
How to Effectively Use ERISA
Providers can use ERISA to their benefit by ensuring their understanding of ERISA and by following these recommendations:
- Verify that the plan is regulated by ERISA
- Obtain written authorization to represent the patient by having an appropriate Assignment of Benefits (AOB).
- Review the "Summary Plan Description" (SPD) to determine the time period of claim submissions, coverage of out-of-pocket expenses, requirements for out-of-network care, benefit payment amounts, and the appeals process. The SPD is the main vehicle for communicating plan rights and obligations to participants and beneficiaries. It is a summary of the material provisions of the plan and it should be understandable to the average member.
- Review the physician's payer contract to determine the physician's rights.
How to File an Appeal
- Gather your evidence:
- Copies of policies;
- Name and credentials of the person who performed the Adverse Benefit Determination (ABD);
- Outside documentation used by the insurance company;
- Information needed by the insurance company to overturn the ABD;
- The Summary Plan Description (SPD);
- The Explanation of Benefits (EOB)/insurance letters; and
- The ERISA laws and regulations.
- FAQs for ERISA.
- Provide a foundation for your appeal and submit it in a timely manner per the appeals process specified in the (SPD).
- Submit everything via certified mail/return receipt.
- Follow up and file grievances if necessary.
- Complaints can be filed to the Department of Labor if ERISA regulations have been violated.
Resources and Tools
- The Employee Benefits Security Administration offers FAQS regarding ERISA.
- EBSA Guide
- Families USA provides appeal rights concerning ERISA.
- The Department of Labor (DOL) Pension and Welfare Benefits Administration provides the final regulation of employee benefit plans covered by ERISA:
Sample Appeal Letters