Your employer self-funds the plan. Here is what you actually have.

Half of this site tells you what California requires of your health plan. Then it adds a line saying none of it applies if your employer self-funds the plan — and stops. That is a gap we created, and roughly half of people with employer coverage are standing in it.

So: your plan pays claims out of the company's own money and rents an insurer's network and logo for the card. California cannot reach it, because federal law says a benefit plan shall not "be deemed to be an insurance company or other insurer… for purposes of any law of any State purporting to regulate insurance companies."¹ That removes the state remedies. It does not leave you with nothing — and on one axis it leaves you with more.

First, confirm it, because the card lies

The insurer's name on your card tells you nothing; level-funded and stop-loss arrangements are self-funded and carry a carrier's brand. Two reliable tests:

Read the summary plan description. It is required to identify "the source of contributions to the plan… and identification of any funding medium used for the accumulation of assets through which benefits are provided."² If benefits come from the employer's general assets, it is self-funded. You can demand that document in writing, and the administrator faces a penalty exposure if it does not arrive within 30 days — though that penalty is capped at $110 a day and is discretionary with a court, so it is a lever, not an invoice.³

Look up the Form 5500. Annual reports are public and searchable, and line 9 asks how the plan is funded, with "general assets of the sponsor" as one of the boxes.⁴ One catch: a self-funded plan covering fewer than 100 people is exempt from filing at all,⁵ so absence from the database proves nothing.

The deadlines you have

Every self-funded group health plan must run a claims procedure, and the clocks are federal:⁶

Two of those rows matter more than the rest for mental health. Urgency is judged by your treating provider, and the plan must honour that determination.⁸ And a request to extend an urgent course of treatment already underway, made at least 24 hours before it runs out, must be decided within 24 hours⁷ — which is the rule for a continued-stay denial in residential or intensive outpatient treatment.

The document right — the part that is better than California's

This is the affirmative story, and almost nobody uses it. On request and free of charge, the plan must give you:

• the internal rule, guideline or protocol it relied on to deny you;⁹
• for a medical-necessity denial, "an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to your medical circumstances";⁹
• "reasonable access to, and copies of, all documents, records, and other information relevant to the claim" — defined broadly enough to include documents showing that the plan applies its rules consistently to other people, whether or not it relied on them here;¹⁰
• the diagnosis and treatment codes, with what they mean;¹¹
• and, under the parity rules, the criteria for medical necessity determinations for mental health and substance use benefits — which any current or potential participant, or a contracting provider, may request, not only someone with a live claim.¹²

Federal regulators have also stated that participants are entitled, on request, to the plan's comparative analysis of how it applies non-quantitative treatment limits to mental health benefits against medical and surgical ones.¹³ Ask for it by that name.

External review, and why it binds

If your plan is not grandfathered, it must offer an external review by an accredited independent review organisation.¹⁴ You have four months from the final denial to request it; the plan does a preliminary review in five business days; the reviewer decides within 45 days, or 72 hours if expedited.¹⁵ And the decision binds: the plan "must provide benefits (including by making payment on the claim) pursuant to the final external review decision without delay, regardless of whether the plan or issuer intends to seek judicial review."¹⁵

Self-funded ERISA plans do not use a state process or the federally administered one — they contract with accredited review organisations and rotate assignments among at least three of them.¹⁶

When the plan does not follow its own rules

There is a sentence here worth knowing by heart. Where a plan fails to strictly adhere to the claims requirements, you are deemed to have exhausted the internal process — you can go straight to external review or to court, and "the claim or appeal is deemed denied on review without the exercise of discretion by an appropriate fiduciary."¹⁷ That last clause matters because it strips the plan of the deferential standard a court would otherwise apply to its judgment.

Do not oversell it to yourself, though. There is a real de minimis exception for violations that cause no prejudice, arose for good cause or beyond the plan's control, and happened inside a good-faith exchange of information — unavailable if the violations are a pattern or practice. You may demand a written explanation of the violation, and the plan has 10 days to give it.¹⁷

What parity still requires

Mental health parity is federal law and it applies to self-funded plans — they are the population it was written for, since Congress could not reach them through state insurance regulation.¹⁸ A 2024 rule expanding the requirements is currently under a non-enforcement policy announced in May 2025 while litigation proceeds,¹⁹ and no rule rescinding or modifying it had been published as of this page's date. But the agencies said in the same statement that the statutory obligations, as amended in 2021, "continue to have effect."¹⁹ The disclosure rights above are unaffected.

Do this, in order: ask for the summary plan description in writing and confirm the funding. Get the denial in writing with the criteria named. Request the criteria, the clinical-judgment explanation and the full relevant file — in one email, citing the sections. File the internal appeal inside 180 days, and say the word "urgent" with your provider's backing if the wait is dangerous. Then take it to external review. If your plan turns out to be state-regulated after all, the California route is stronger → · what California requires on appointment waits →

Sources

1. 29 U.S.C. §1144(a) (preemption of state laws relating to employee benefit plans), §1144(b)(2)(A) (savings clause for state laws regulating insurance) and §1144(b)(2)(B) (the deemer clause, quoted) — uscode.house.gov. The practical result: California's timely-access standards, its Independent Medical Review and its medical-debt reporting rules operate on insurers and health care service plans, and so reach a fully insured plan but not a self-funded one.
2. 29 C.F.R. §2520.102-3(q); subdivision (s) additionally requires the summary plan description to set out the claims procedures and "applicable time limits."
3. 29 U.S.C. §1024(b)(4) (documents on written request) and §1132(c)(1)(B) — an administrator who fails to furnish requested information "within 30 days after such request" "may in the court's discretion be personally liable… in the amount of up to $100 a day," raised to $110 by 29 C.F.R. §2575.502c-1.
4. 29 U.S.C. §1026(a) (annual reports are public information); the Department of Labor's Form 5500 search at efast.dol.gov; line 9 of the Form 5500 asks the funding and benefit arrangement, with "general assets of the sponsor" among the options.
5. 29 C.F.R. §2520.104-20 — a welfare plan covering fewer than 100 participants and paying benefits solely from general assets is not required to file an annual report.
6. 29 C.F.R. §2560.503-1 — (f)(2)(i) 72 hours for urgent claims with a 24-hour missing-information notice; (f)(2)(iii)(A) 15 days pre-service; (f)(2)(iii)(B) 30 days post-service; (h)(3)(i) at least 180 days to appeal; (i)(2)(i)–(iii) the appeal clocks — ecfr.gov.
7. 29 C.F.R. §2560.503-1(f)(2)(ii) — reducing or terminating an approved ongoing course of treatment is itself an adverse benefit determination requiring advance notice, and a request to extend urgent concurrent care made at least 24 hours before it expires must be decided "within 24 hours after receipt."
8. 29 C.F.R. §2560.503-1(m)(1) (definition of urgent) and 45 C.F.R. §147.136(b)(2)(ii)(B), which specifies that urgency is "as assessed by the treating provider, whose determination the plan or issuer must honor."
9. 29 C.F.R. §2560.503-1(g)(1)(v)(A)–(B), and the parallel requirements on an appeal denial at (j)(5).
10. 29 C.F.R. §2560.503-1(h)(2)(iii) and the definition of "relevant" at (m)(8).
11. 45 C.F.R. §147.136(b)(2)(ii)(E) — the diagnosis and treatment codes and their meanings, on request.
12. 29 C.F.R. §2590.712(d)(1) — the criteria "must be made available by the plan administrator… to any current or potential participant, beneficiary, or contracting provider upon request"; (d)(2) requires the reason for a denial to be made available in the manner required by the claims regulation.
13. 29 U.S.C. §1185a(a)(8), added by the Consolidated Appropriations Act, 2021, requires plans to perform and document comparative analyses of non-quantitative treatment limitations and produce them to the Secretary. The statute itself speaks to the Secretary; the participant's right to request them rests on ERISA §104(b) as stated by the Departments of Labor, Health & Human Services and the Treasury in their parity implementation FAQs, Part 45, Q6 — dol.gov.
14. 45 C.F.R. §147.136 and 29 C.F.R. §2590.715-2719 — external review, not applicable to grandfathered plans. Reviewable determinations include any denial "that involves medical judgment," which covers medical-necessity and level-of-care denials.
15. 45 C.F.R. §147.136(d) — four months to file; preliminary review within five business days with notice within one business day; 45 days for a standard decision; 72 hours expedited; and the requirement to pay "without delay, regardless of whether the plan or issuer intends to seek judicial review."
16. Department of Labor Technical Release 2011-02 (22 June 2011) — the safe harbour for self-insured plans subject to ERISA, requiring contracts with at least three accredited review organisations and rotation among them — dol.gov.
17. 45 C.F.R. §147.136(b)(2)(ii)(F)(1)–(2) — deemed exhaustion on a failure to strictly adhere, the quoted "deemed denied on review without the exercise of discretion" language, the de minimis exception and its pattern-or-practice limit, and the 10-day written explanation. Note that the similar-sounding provision at 29 C.F.R. §2560.503-1(l)(2) applies to disability claims, not health claims, and is frequently miscited here.
18. 29 U.S.C. §1185a and 29 C.F.R. §2590.712.
19. "Requirements Related to the Mental Health Parity and Addiction Equity Act," 89 Fed. Reg. 77586 (23 September 2024), effective 22 November 2024; Statement of the Departments of Labor, Health & Human Services and the Treasury, 15 May 2025, announcing that they "will not enforce the 2024 Final Rule" pending a final decision in litigation brought by the ERISA Industry Committee plus 18 months, while confirming that "MHPAEA's statutory obligations, as amended by the CAA, 2021, continue to have effect" — dol.gov. We checked the Federal Register through 17 August 2026 and found no rule or proposed rule rescinding or modifying the 2024 regulation; the litigation's current posture is not something we can confirm from a primary source, so this page states only the agencies' last published position.

Every provision above was read on the regulation or statutory text on 17 August 2026. This page describes federal law; it is not legal advice.