Why this is the first question, not a technicality
Almost every useful protection described on this site is state law. New York’s version of parity, its surprise billing framework, its external appeal, its insulin rule: all of them attach to plans New York regulates.
A self-funded employer plan is not one of those. It is governed by federal law, which has its own protections, and the state cannot enforce against it on your behalf.
So when a page tells you to call the Department of Financial Services, that advice is correct for one reader and the wrong address for another. Which one you are is decided by a fact you can establish in a minute.
What changes, concretely
| Protection | Fully insured | Self-funded |
|---|---|---|
| New York’s external appeal through DFS | Yes | No; the federal external review process applies instead |
| New York’s surprise billing framework and independent dispute resolution | Yes | No; the federal No Surprises Act applies |
| New York’s parity additions — the primary-care copay ceiling for outpatient mental health, the ban on preauthorization for in-network OASAS-certified addiction treatment | Yes | No; the federal parity act still applies |
| New York’s insulin rule (no cost sharing) and the asthma inhaler law | Yes | No |
| Where a complaint goes | Department of Financial Services, 800-342-3736, or the Attorney General’s Health Care Bureau, 800-428-9071 | US Department of Labor, 866-444-3272 |
The federal floor still exists in every row. What disappears is the New York layer on top of it, and on this site that layer is usually the part that gives you a specific number to quote.
The situations where it decides the outcome
A denied service. Fully insured: internal appeal, then an external appeal through the Department of Financial Services, decided by a reviewer who does not work for your insurer. Self-funded: internal appeal, then federal external review. How appeals work.
A therapy copay higher than your primary care copay. Fully insured: New York caps it at the primary care copay for outpatient mental health at a state-licensed facility, and that is enforceable. Self-funded: the federal parity act applies, the specific state ceiling does not. How parity works.
Outpatient addiction treatment at an OASAS-certified in-network facility. Fully insured: preauthorization is barred, and so is concurrent review for the first two weeks or 14 visits. Self-funded: not by state law.
An out-of-network ground ambulance bill. Fully insured: New York’s emergency-services protections and its dispute process may reach it. Self-funded: the federal No Surprises Act governs, and ground ambulances are the gap it did not close. Ambulance bills.
Insulin. Fully insured: no cost sharing at all since January 1, 2025. Self-funded: the state rule does not reach the plan. Insulin in New York.
Who this does not apply to
Plans bought through NY State of Health, individual or small group, are regulated by New York. No question to ask.
Medicaid, the Essential Plan and Child Health Plus run on their own frameworks, with the fair hearing as the backstop rather than an external appeal.
Medicare has its own rules and its own appeal ladder.
The question only arises for coverage through an employer, and that is exactly where people assume they already know the answer.
What to do with the answer
Write it down somewhere you will find it again, with the plan name. Two facts, one line:
[Plan name] — fully insured / self-funded — [date asked]
Everything else on this site branches off it. It is the cheapest thing you can know about your own coverage, and almost nobody knows it.
Questions people ask
How do I know if my plan is self-funded?
Ask HR: “Is our health plan fully insured or self-funded?” The card does not say, and benefits staff answer this routinely.
Why does it matter?
Because New York’s protections attach to plans the state regulates. A self-funded employer plan is governed by federal law, so the state cannot enforce its rules for you.
Does a self-funded plan have no protections?
It has federal ones, including the federal parity act, the No Surprises Act and federal external review. What it lacks is the New York layer on top.
My card says a big insurer’s name. Doesn’t that make it insured?
No. On a self-funded plan the carrier is administering claims for your employer, not insuring them. Same logo, different law.
Where do I complain about a self-funded plan?
The US Department of Labor, at 866-444-3272, rather than the state Department of Financial Services.
Does this apply to a plan I bought myself?
No. Individual and small group plans bought through NY State of Health are regulated by New York.
Sources
- NYS Department of Financial Services (checked 2026-09-13)
- New York Attorney General — behavioral health parity laws (checked 2026-09-13)
- NY State of Health (checked 2026-09-13)
More in Health Insurance Companies in New York: Who They Are and How They Differ
- How to Verify a Provider Takes Your Plan — Directories are wrong often enough that the industry has a name for it. The two-question call that settles it, the log that turns a bad directory into a complaint, and the four things nobody checks.
- Fidelis Care: What to Know Before You Pick It — Fidelis Care is one of the largest Essential Plan and Medicaid carriers in New York State. What its statewide reach means for your network, and the questions to ask first.
- EmblemHealth and MetroPlus: New York's Two Local Plans — MetroPlus belongs to the city's public hospital system; EmblemHealth is the old GHI and HIP. What each one is good for, and who should look at which.
This page explains how the system works. It is not medical advice. More.