ERISA vs non-ERISA — who has jurisdiction?

Statute-pinned · primary sources only

How to tell which one you have

ERISA self-funded plans are typically offered by large employers that pay claims directly out of company funds. The insurance company is the third-party administrator (TPA), not the risk-bearer.

Check your insurance card — many self-funded plans say "Administered by [Insurer]" or list a TPA name.
Check your Summary Plan Description — ERISA plans must provide one; it explicitly identifies the plan as ERISA-governed.
Ask HR — your employer's benefits team can confirm.
If you bought it on the Marketplace or directly from an insurer, it's almost certainly fully-insured (not ERISA self-funded).

What changes if your plan is ERISA self-funded

State DOI has no jurisdiction. Under 29 U.S.C. §1144, ERISA preempts state laws "insofar as they relate to" employee benefit plans. State DOI cannot enforce against your plan.
State balance-billing laws don't reach you. Even if your state has a state IDR pathway or a state ground-ambulance law, it applies only to state-regulated insurance — not self-funded plans.
NSA still applies. The federal No Surprises Act covers ERISA self-funded plans. Federal IDR runs through 45 CFR §149.510.
Enforcement is federal. The Department of Labor's Employee Benefits Security Administration (DOL/EBSA) enforces ERISA compliance, including NSA-related plan obligations. File an appeal denial with DOL/EBSA after exhausting your plan's internal appeal.

Where each plan routes

Payer × service-type matrix

Where each plan + service routes

Payer ↓ / service →	ER	OON anc.	Air amb.	Ground amb.	Scheduled OON
Commercial fully-insured	Federal IDR + NSA complaint + State DOI overlay 45 CFR §149.510	Federal IDR + NSA complaint + State DOI overlay 45 CFR §149.510	Federal IDR + NSA complaint PHSA §2799A-5	State law (if any) + Negotiate otherwise State DOI	NSA waived if 72h consent + Ancillary still protected PHSA §2799B-2
Self-funded ERISA	Federal IDR + NSA complaint + DOL/EBSA enforcement 45 CFR §149.510	Federal IDR + NSA complaint + DOL/EBSA enforcement 45 CFR §149.510	Federal IDR + NSA complaint + DOL/EBSA enforcement PHSA §2799A-5	ERISA preempts state law + Negotiate directly 29 U.S.C. §1144	NSA waived if 72h consent + Ancillary still protected PHSA §2799B-2
Medicare Advantage	Federal IDR + NSA complaint 45 CFR §149.510	Federal IDR + NSA complaint 45 CFR §149.510	Federal IDR + NSA complaint PHSA §2799A-5	State law (if any) State DOI	NSA waived if 72h consent PHSA §2799B-2
Original Medicare	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE	Medicare beneficiary rules 1-800-MEDICARE
Uninsured / self-pay	PPDR (if GFE delta ≥ $400) + Negotiate otherwise 45 CFR §149.620	PPDR (if GFE delta ≥ $400) 45 CFR §149.620	PPDR (if GFE delta ≥ $400) 45 CFR §149.620	Negotiate / charity care —	PPDR (if GFE delta ≥ $400) 45 CFR §149.620

What stays the same

Regardless of whether your plan is ERISA or state-regulated, the patient's first action is the same:

File an NSA complaint with the CMS No Surprises Help Desk at 1-800-985-3059. 90-calendar-day window.
Pay only your in-network cost-share for an NSA-covered service.

Why this matters for your state DOI complaint

If you file with your state DOI and your plan is self-funded ERISA, the DOI will likely close the complaint citing lack of jurisdiction. That doesn't mean you have no recourse — it just routes the complaint to the wrong agency. The correct federal route is the CMS NSA Help Desk (for NSA-specific violations) and DOL/EBSA (for plan-level appeal denials).

Related healthcare resources

MedigapWindow

Medicare Supplement Open Enrollment Period decoder + 50-state rule grid.

PartDExtraHelp

Part D Low-Income Subsidy (LIS) eligibility + 4-MSP overlay.

PetInsuranceDenied

Denial-appeal pattern recognition (consumer health-insurance-adjacent).

Informational, not medical, legal, or insurance advice. Consult a healthcare-billing attorney or patient-advocate before acting on a No Surprises Act dispute. The free CMS NSA complaint pathway is 1-800-985-3059.