Which document proves whether my plan is self-funded?

The Summary Plan Description. Federal rules require the SPD to identify the funding medium of the plan, and specifically to say whether and to what extent benefits are guaranteed under a contract or policy of insurance issued by an insurance company (29 CFR 2520.102-3(q)). A plan whose SPD says an issuer guarantees benefits is fully insured. A plan whose SPD names a third-party administrator but carries no insurance guarantee is self-funded. The regulation text was checked on 18 August 2026.

My insurance card says a national carrier. Doesn't that mean I am insured?

Not necessarily. A self-funded employer commonly hires a national carrier to process claims and rent out its provider network, an arrangement usually labeled administrative services only, or ASO. The card looks identical to an insured card. The claims still come out of the employer's own money. The card is a clue, not proof.

How do I make my employer hand over the plan documents?

Ask the plan administrator in writing. ERISA section 104(b)(4), at 29 U.S.C. 1024(b)(4), requires the administrator to furnish, on written request by a participant or beneficiary, the latest summary plan description, the latest annual report, and the contract or other instruments under which the plan is established or operated. If the administrator does not comply within 30 days, a court may in its discretion hold it personally liable for up to $110 a day (29 U.S.C. 1132(c)(1), raised from the statutory $100 by 29 CFR 2575.502c-1). The award is discretionary, so treat the 30 days as leverage rather than as a promise.

Does being self-funded mean I have fewer appeal rights?

No. The federal claims procedure rules at 29 CFR 2560.503-1 and the internal appeal and external review requirements apply to employer group health plans whether or not benefits are insured (grandfathered plans are the main exception), and the No Surprises Act reaches group health plans generally (45 CFR 149.20(a)(1)). What a self-funded plan removes is state-specific protection: state benefit mandates, the state insurance department as a complaint venue, and in most cases the state external review process.

Self-Funded or Fully Insured? How to Find Out for Sure

You call the state insurance department because the plan denied a claim and the appeal went nowhere. You wait on hold. Then the person who picks up asks for the name of your employer, types for a moment, and says the plan is self-funded, so the department has no jurisdiction over it. Had it been fully insured, she adds, this would have been her file.

That answer is not a brush-off. For roughly two out of three people with job-based coverage in the United States, it is legally correct. In the 2025 KFF Employer Health Benefits Survey, 67% of covered workers were in self-funded plans, including 80% at firms of 200 or more workers. Those employers pay claims out of their own money and buy no insurance policy at all. And a state insurance regulator regulates insurance.

So before you spend another week writing to the wrong agency, settle the funding question. It takes one document and one sentence.

One housekeeping note before the procedure. I checked every regulation cited here against the eCFR text on 18 August 2026, and each citation is hyperlinked so you can open the paragraph and read it without taking my word for anything. I am not a lawyer or a benefits professional, and this page is about documents and deadlines, not about what you should do with your particular claim.

What the answer actually changes

ERISA supersedes state laws that "relate to" an employee benefit plan (29 U.S.C. 1144(a)). Then it gives most of that ground back for insurance: nothing in the statute exempts anyone from a state law that regulates insurance, at 1144(b)(2)(A), the savings clause. Then it takes the ground back again for plans that are not insured. A benefit plan cannot be "deemed to be an insurance company or other insurer" for purposes of any state law regulating insurance companies or insurance contracts, at 1144(b)(2)(B), the deemer clause.

Read those three sentences in order and the practical rule falls out. If your employer bought an insurance policy, the state can regulate that policy, and through the policy, your coverage. If your employer bought nothing, the state has nothing to grab.

What that moves:

State benefit mandates. The infertility coverage, the hearing aid benefit, the minimum number of physical therapy visits your legislature passed — fully insured plans follow them, and self-funded private employer plans generally do not.
Where a complaint goes. If you are insured, the state insurance department. If you are not, the U.S. Department of Labor's Employee Benefits Security Administration, which runs a benefits advisor line at 1-866-444-3272 and an online intake form at askebsa.dol.gov.
External review routing, which is the one that decides where the file physically gets mailed. It gets its own section below.

What does not move is worth saying out loud, because plan staff sometimes imply otherwise. The federal claims and appeals rules at 29 CFR 2560.503-1 apply to ERISA plans whether insured or not. The internal appeal and external review architecture applies to group health plans generally, the main exception being grandfathered plans — and even those keep external review for surprise-billing claims (45 CFR 147.136(a)(1)(ii)). So do the No Surprises Act protections, which by their terms reach group health plans (45 CFR 149.20(a)(1)). Your 180 days did not shrink because your employer self-funds.

The sentence that settles it

Open the Summary Plan Description. Not the glossy benefits guide from open enrollment, and not the four-page Summary of Benefits and Coverage. The SPD is the document ERISA requires, and one of the items it must contain is the identity of the funding medium:

The identity of any funding medium used for the accumulation of assets through which benefits are provided. The summary plan description shall identify any insurance company, trust fund, or any other institution, organization, or entity which maintains a fund on behalf of the plan or through which the plan is funded or benefits are provided. If a health insurance issuer ... is responsible, in whole or in part, for the financing or administration of a group health plan, the summary plan description shall indicate the name and address of the issuer, whether and to what extent benefits under the plan are guaranteed under a contract or policy of insurance issued by the issuer, and the nature of any administrative services (e.g., payment of claims) provided by the issuer.

— 29 CFR 2520.102-3(q)

The bolded clause is the whole test. Search the SPD file for guaranteed, policy of insurance, underwritten, self-funded, and general assets. One of four things comes back.

What the SPD says	What it means
"Benefits are guaranteed under a group insurance policy issued by [carrier]"	Fully insured. State insurance law reaches you.
"Benefits are self-funded by the Employer. [Carrier] provides administrative services only"	Self-funded. ERISA territory.
"The Plan is funded through the general assets of the Employer"	Self-funded, written in accounting language.
The carrier appears only as claims administrator, with no guarantee language anywhere	Almost certainly self-funded. Confirm against one more source before you act on it.

That last row is the common one, and it is common because the drafting is lazy rather than deceptive. Do not stop at "the carrier is mentioned." Look for the verb.

There is a second heading to search for, and it predates the funding paragraph. ERISA's disclosure regulation requires the SPD to state "the type of administration of the plan, e.g., contract administration, insurer administration, etc." (29 CFR 2520.102-3(e)), which is why so many SPDs carry a short block headed Type of Administration alongside the plan name, plan number and plan year. Read it with the funding sentence rather than instead of it. Contract administration describes who processes claims and settles nothing about who pays them, while insurer administration sitting next to guarantee language is two sources agreeing.

Getting the SPD when HR goes quiet

Most people never get past this step, which is why most people never learn the answer.

The request is statutory, not a favor. ERISA section 104(b)(4) (29 U.S.C. 1024(b)(4)) says the plan administrator shall, upon written request of any participant or beneficiary, furnish a copy of the latest summary plan description, the latest annual report, and "the bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated." The administrator may charge a reasonable copying cost, so expect a small invoice for a paper copy and ask for the PDF instead.

Two details decide whether the request works.

Address it to the plan administrator, not to your manager. The plan administrator is usually the employer itself, named as such on the last pages of the SPD or on the Form 5500 filing. If you cannot find the name, write to HR and state that the letter is a request under ERISA section 104(b)(4) directed to the plan administrator. That phrasing tends to get the message forwarded to somebody who recognizes it.

Name the 30 days. If the administrator fails or refuses to comply with a request for information it is required to furnish, within 30 days of the request, a court may in its discretion hold the administrator personally liable to you for up to $100 a day under 29 U.S.C. 1132(c)(1). The Department of Labor raised that ceiling to $110 a day by regulation. Nobody is promising you $110 a day, and the award is discretionary. The point is that the deadline sits in a statute, and a written request that cites it lands differently from an email asking for paperwork.

Ask for the plan document itself, not only the summary. When the two disagree, the governing document usually decides, and that fight deserves its own page.

Weaker clues, ranked by how much they are worth

You may need a working answer today, before the SPD arrives. These are ordered, and none of them is proof.

1. The Form 5500 filing. Your employer's annual report is public and searchable at efast.dol.gov. A welfare plan that bought insurance attaches a Schedule A listing the contract; a self-funded plan generally has no Schedule A covering medical benefits, though it may have one for stop-loss or for dental and vision bought separately. This is the strongest clue short of the SPD, and it deserves a walkthrough of its own.

2. The wording on the ID card and the EOB. Look for "administered by," "administrative services only," "ASO," or your employer's own name in the plan field. Look for the absence of the state insurance department notice that insured policies usually carry. Cards are designed by marketing departments and prove nothing on their own.

3. Whether a state mandate reached you. If your state requires coverage of a service and your plan excludes it flatly, that asymmetry points toward self-funding.

4. Headcount. Weak, but real. In the same KFF survey, 80% of covered workers at firms with 200 or more workers were in self-funded plans, against 27% at firms of 10 to 199.

A trap sits inside that last number. A level-funded plan is usually a self-funded plan wearing a premium's clothes — KFF calls the arrangement nominally self-funded. The employer sends one flat figure every month, most of it into a claims account the employer still owns, with stop-loss coverage capping what a bad year can cost. Thirty-seven percent of covered workers at firms of 10 to 199 were in one in 2025. So your HR contact may sincerely believe the company buys insurance, and still be describing a plan that funds its own claims. Which side of the line it falls on is a question for the plan documents, not for the billing arrangement.

And one clue that looks strong and is not. A notice telling you that you may bring a civil action under section 502(a) proves only that you are in an employer plan: 29 CFR 2560.503-1 applies to ERISA plans whether the employer buys a policy or funds the claims itself, so fully insured group coverage carries that sentence too. The line that does discriminate is the external review instruction — a state process and a state insurance department point one way, an IRO assigned by the plan under the federal process points the other. Even that is a pointer rather than proof, for reasons the next section sets out.

Where the file goes once you know

External review routing is spelled out in 45 CFR 147.136, and it splits on exactly this question.

If benefits are provided through insurance and the state runs an external review process meeting the NAIC Uniform Model Act minimums, the issuer follows the state process and neither it nor the plan has to use the federal one, at 147.136(c)(1)(i). If the plan provides benefits other than through insurance, that is, the plan is self-insured, it follows a state process only where that process actually applies to and binds the plan and is not preempted by ERISA, at 147.136(c)(1)(ii). Most self-insured private plans are bound by no such process, and they land in the federal external review process of paragraph (d). One wrinkle sits in the same paragraph: where a state has opened its process voluntarily to plans it cannot bind, a self-insured plan offered that door may take either route.

A self-insured plan running the federal process must assign an IRO accredited by URAC or a similar nationally recognized accrediting organization, must contract with at least three IROs, and must rotate claims among them, at 147.136(d)(2)(iii)(A). You do not choose the reviewer. Neither, in any single case, does the plan.

If you work for a city, a county, a school district, or a state agency, read one more line. Self-insured non-federal governmental plans are not ERISA plans, and 147.136(d)(4) lets them elect either the federal external review process or the federally administered process HHS sets out in guidance. Two public employees in the same state can be on different tracks. Church plans are their own category again. In every one of these cases the answer is in the plan documents, not in a general rule you can look up once and reuse.

Once you know the track, the deadline map in internal appeal vs external review tells you which clock is running right now. If you are still decoding the letter itself, start with how to read a denial letter. And if a provider bill is sitting next to the denial, request the itemized version before you pay any part of it.

Three lines to put in the file this week

Write these where the rest of the claim paperwork lives:

The date you mailed the section 104(b)(4) request, and the date 30 days after it. Certified mail if you can manage it, because the date is the leverage.
The funding sentence from the SPD, quoted exactly, with its page number. You will quote it again, and you do not want to be hunting for it under a deadline.
The name of the agency that takes your complaint given that answer: the state insurance department, or EBSA at 1-866-444-3272. Writing to the wrong one costs weeks that nobody refunds.

Check that the agency you pick has jurisdiction over your plan before you spend a letter on it. EBSA's benefits advisors take these questions by phone and through askebsa.dol.gov, but ERISA title I does not reach governmental plans or church plans that have not elected in (29 U.S.C. 1003(b)(1) and (2)), so a school district employee writing to EBSA is writing to the wrong desk. A state insurance department can act on an insurance contract and on the issuer that wrote it, and has no authority over a self-funded employer's benefit decisions. The funding sentence you copied out above is what tells you which of those two descriptions is yours.

Rules get amended and my reading carries no authority. Open each linked paragraph and check the currency date on the eCFR page against the date at the top of this one.