Which kind of health plan: reading the card and the letter in Texas
In short
- TDI gives the quickest test of the plan type: the ID card.
- "TDI" or "DOI" on the card means a fully insured plan regulated by TDI.
- No "TDI" or "DOI" on the card means, TDI says, that the plan is self-funded.
Appeal steps depend on the kind of plan. The Texas Department of Insurance (TDI) gives the quickest test: the ID card. This page sets out what TDI's pages and the federal notice rules say. When the card and the letter do not settle it, the plan documents or the benefits office at work can.
The card
- "TDI" or "DOI" on the card: a fully insured plan, regulated by TDI.
- Bought directly from an insurance company or HMO, or through HealthCare.gov: TDI says it is "likely a fully insured plan".
- No "TDI" or "DOI": TDI says this means the plan is self-funded. Most people with a health plan in Texas have one, usually through an employer that "pays claims itself".
- "Administered by" an insurance company, or "ASO": TDI says these card words point to a self-funded plan; the insurer handles only the paperwork.
The letter
- A job-based plan covered by ERISA must state the right "to bring a civil action under section 502(a)" of ERISA after an appeal (29 CFR 2560.503-1(g)(1)(iv)). That line shows the federal job-based rules apply. It appears on both insured and self-funded job plans, so the card still decides the outside-review route.
- Marketplace and other ACA plans must give contact details for a consumer assistance office or ombudsman (45 CFR 147.136(b)(2)(ii)(E)(5)).
- Medicare Advantage letters use Medicare's own terms, such as "reconsideration".
Plans TDI does not regulate, and where TDI sends people
| Plan | Where TDI points |
|---|---|
| Self-funded plan from a private employer | U.S. Department of Labor |
| Self-funded plan from a school district, government, union or church | The complaint steps in the plan's benefits booklet |
| State employees | Employees Retirement System (ERS) |
| TRS-Care | Teacher Retirement System of Texas |
| University of Texas employees | The University of Texas System |
| Federal employees | U.S. Office of Personnel Management |
| Medicare | U.S. Department of Health and Human Services |
| Medicare Advantage | The plan itself (TDI: call the plan) |
| Medicaid; CHIP plans that aren't HMOs | Texas Health and Human Services Commission |
| Military (TRICARE) | TRICARE |
| City and county employees | The plan's benefit booklet |
What each kind means for an appeal
- TDI or DOI: the plan's own appeal, then the Texas outside review (see the Texas outside review page).
- Self-funded private job plan: the plan's appeal under federal rules, then federal external review (see that page).
- Marketplace: the plan's appeal (one internal level, 45 CFR 147.136(b)(3)(ii)(G)), then the external review the final letter names.
- Medicare Advantage: a reconsideration by the plan; if the plan keeps its denial, it must send the case to an independent reviewer itself (42 CFR 422.590).
- ERS HealthSelect: two internal levels, then an IRO (see the ERS page).
When it is still unclear
TDI says to look at the plan documents or talk to the benefits administrator at work. TDI's line also takes questions: 800-252-3439.
Free public help
- The plan's member line, printed on the card.
- Texas Department of Insurance: 800-252-3439.
- Office of Public Insurance Counsel (OPIC), the state office that speaks for insurance consumers: 1-877-611-6742.
- Texas Medicare help line: 800-252-9240.
What Denial Reply prepares
The free decoder at /decode asks which marks the card and the letter carry, then shows the route and dates that apply. It needs no upload. Denial Reply prepares appeal paperwork for Texas adults from the denial letter and records.
Related guides: federal outside review · Texas outside review · Medicare neck fusion rules
Who, how, why
- Who: Denial Reply. Drafted with AI and checked by the founder, who is not a doctor and is not licensed to practice law.
- How: From three TDI consumer pages and the federal notice rules, all read November 3, 2026 (linked below).
- Why: To help people find which appeal steps apply. It is general information, not legal or medical advice.
Sources
- TDI, insurance tips page on fully insured and self-funded plans: https://www.tdi.texas.gov/tips/fully-insured-vs-self-insured.html (updated 12/17/2025; read 2026-11-03)
- TDI, "How to file a complaint about a self-funded health plan": https://www.tdi.texas.gov/consumer/selffundedplans.html (updated 6/23/2023; read 2026-11-03)
- TDI, "Getting help with a health plan that TDI doesn't regulate": https://www.tdi.texas.gov/consumer/getting-help-with-a-health-plan-that-tdi-doesnt-regulate.html (updated 12/17/2025; read 2026-11-03)
- 29 CFR 2560.503-1: https://www.law.cornell.edu/cfr/text/29/2560.503-1 (read 2026-11-03)
- 45 CFR 147.136: https://www.law.cornell.edu/cfr/text/45/147.136 (read 2026-11-03)
- 42 CFR 422.590: https://www.law.cornell.edu/cfr/text/42/422.590 (read 2026-11-03)