State and local government employee plans, and what decides a weight treatment request

Which plans this page is about

The federal employee benefit statute defines a governmental plan as one a government establishes or maintains for its employees, and it names the United States, a state, a political subdivision of a state, and an agency or instrumentality of any of those.

The phrase people reach for is state employee plan, and the class the statute writes is wider. A county, a city, a school district, a public university and a transit authority are political subdivisions or instrumentalities, so a plan one of them runs for its own workers sits in the same class as the plan a state runs for its own. Whether a particular employer is inside that definition is a question about that employer, and this page answers it for none of them.

The statute most employer coverage runs on steps aside here

The federal employee benefit statute says its own provisions do not apply to a governmental plan. A plan in that class is outside the statute rather than governed by a quieter part of it, and everything below follows from that one sentence.

The preemption section of the same statute supersedes state law only for a plan described in its coverage section and not exempt under the exceptions. A governmental plan sits in those exceptions, so the sentence that lifts state law off a private self-funded plan never reaches this one. That is the inverse of the answer on the self-funded employer page, and it is worth reading twice, because most writing about employer coverage is describing the private case.

Preemption not applying is not the same thing as a state insurance mandate applying. What reaches a government employer plan instead is whatever that state wrote for its own public employees, and that is a question with fifty-one answers. Covered Weight has read the public employee law of no state, so this page answers it for none of them.

The private version of this question is the opposite shape, and it is worth reading beside this one: what a self-funded employer plan can exclude describes a plan that is outside state insurance law precisely because that statute does reach it.

Federal law still sets a floor under the plan

A government employer plan is still a group health plan, so the Public Health Service Act requirements published in title 45 of the federal regulations reach it. One federal statute stepping aside does not leave the plan outside federal law.

The internal claims and appeals standard is one of those requirements. The regulation sends a group health plan to the Department of Labor claims procedure rule, so a government employer plan runs on the same internal appeal standard as a private one and arrives there through the Public Health Service Act rather than through the employee benefit statute.

One election exists here that no other kind of plan has

A sponsor of a non-federal governmental plan may elect to exempt the plan from named requirements, and only to the extent the plan is not provided through health insurance coverage. Where the plan is not governed by a collective bargaining agreement the regulation has the sponsor file that election with the Centers for Medicare and Medicaid Services before the first day of the plan year.

The regulation introduces that list as the requirements subject to exemption and then names them, so the list is what an election can reach. No weight treatment, no drug benefit and no internal appeal or external review requirement appears in it. The statute behind the regulation draws its own boundary in the same direction, saying the election is not available with respect to the provisions of two named subparts. A reader holding an opt-out notice is holding a list of named requirements rather than an exit from federal law.

If a plan made that election, it owes each enrollee a notice

A plan that makes the election has to notify each affected enrollee of it and explain what the election means for them. The duty sits in the regulation and the statute above it repeats it.

The notice has to be in writing, and it has to reach each enrollee at the time of enrollment under the plan and again on an annual basis.

The regulation lets a plan meet the requirement by printing the notice prominently in a summary plan description or an equivalent description. So the document to search is the booklet already in a reader's hands rather than a separate letter that may never have arrived.

Where an external review goes is a question about the plan, not the state

The external review requirement reaches these plans, and which process carries it out is not settled by the state a reader lives in. For every other payer class on this site that answer follows from the jurisdiction.

Where a self-insured plan is not subject to a state external review process and the state has opened its process to plans it does not otherwise reach, the regulation lets the plan choose between that state process and the federal one. A later paragraph lets a self-insured non-federal governmental plan elect either the federal external review process or the federally administered process the agency sets out in guidance. In each of those sentences the chooser is the plan.

No deadline is published on this page. The external review clock is read once on the external review page, and a second copy here would be the same figure maintained in two places, which is how two copies of one deadline end up disagreeing. The external review clock is read there, against the jurisdictions this site publishes.

What none of these documents answers

Not one document behind this page names a drug, an indication or a weight treatment. They settle which body of rules applies to the plan and they never settle what the plan pays for. The benefit booklet and the pharmacy documents the sponsoring government adopts are where an obesity treatment answer is written, which is why a plan in this class can cover a treatment the plan in the next state excludes without either of them departing from federal law.

This record reads federal law and stops there. It reads no plan's benefit booklet, it reads the public employee law of no state, and it carries no list of which sponsors have filed an election. So the list above describes what an election can reach rather than what any particular plan has done, and the absence of a section on a reader's own program is a limit of what was read.

This record describes the federal rules that decide which regime a government employer plan sits in. It does not describe what any plan covers, it does not reach a federal civilian employee plan under the Federal Employees Health Benefits Program, and it does not reach a private employer plan of any kind.

If a government employer plan is not the coverage you are asking about, work out which of the eight kinds of plan is yours first, because the document that governs the answer changes with it. If a request has already been refused, the appeal route for each plan type names the body that hears it.

Documents this page reads