Give them a person to call.
Plan questions tend to arrive in March, long after open enrollment ends. Employees are better served by a named person than by a phone menu.
Four things a named contact changes.
Plan questions do not wait for open enrollment.
Questions get asked early
When employees know who to call, they ask before the bill, not after it.
HR stops being the only help desk
A named benefits contact takes plan questions off the HR team without leaving employees on their own.
Claims problems get an owner
A billing dispute or a denied claim is easier to resolve when someone is already looking at it with the employee.
The same answer every time
One contact, working from the same plan documents, gives consistent answers instead of three different versions.
What the rules say.
Each figure and requirement here traces to the federal sources listed at its end. This is general information, not legal advice.
At least 180 days to appeal
Federal rules give a participant in a group health plan no less than 180 days from the date of a denial notice to lodge an appeal.
The plan has a deadline to decide
A plan with just one appeal level must respond within 30 days when the care has not yet been received, or 60 days when it has. Two-level plans allow less time at each stage.
External review is available
Federal rules also require covered plans to offer review by an independent outside party. The employee has four months from the last internal denial to ask, and a routine ruling follows in 45 days.
Urgent situations move faster
When waiting would seriously endanger the patient’s health, the outside reviewer must decide an expedited request within 72 hours.
Sources: 29 CFR 2560.503-1
How a Michigan employee can challenge a denial.
Michigan offers a no-cost state external review, but only for insured coverage. Self-funded employer plans usually follow the federal route, so confirm which funding type your plan uses before pointing an employee to either.
Start with the insurer
With an insured plan, a carrier must rule on an internal appeal in 30 days for care still to come and 60 days for care already delivered.
Then the state, at no cost
When the carrier holds firm, or never replies in time, the employee can ask the state insurance regulator, the Department of Insurance and Financial Services (DIFS), to arrange a free outside review.
The window is 127 days
The deadline to file is 127 days from the carrier’s last decision. Requests go through the DIFS website or on the DIFS form, with the denial letter and supporting papers enclosed.
Urgent cases move faster
Urgent situations work differently: the employee asks the plan for a fast-track appeal and then, ten days after the plan’s closing decision at the latest, sends DIFS a request along with a note from the treating doctor. A ruling comes back in 72 hours.
Questions can go to the DIFS help line, 877-999-6442, weekdays 8 a.m. to 5 p.m. Sources: Michigan DIFS: appealing a denied claim | DIFS press release, June 2026
CFH clients send employees to us.
Our role is to help employees pick the right plan for their circumstances and to field plan questions all year. HR stays in charge of the relationship while we handle the details.
Related pages.
Who should an employee call about a claim they do not understand?
A good first call is the member services line printed on the ID card; the representative can walk through how the claim was handled.
Staying Available After Open Enrollment
Plan confusion does not end when enrollment closes.
Denied Claims and Appeals
Denied-claim steps and how the appeal process works.
Avoiding Group Health Insurance Plan Confusion
Our complete guide to helping employees make sense of their group health plan.
Questions that come up next.
Quick replies to the follow-up questions employees raise next, each linking to its own page.
Why did we get a bill after a visit that only had a copay?
Often the copay pays for the visit itself and nothing more. Labs, imaging, procedures, facility charges and out-of-network providers may each show up as a separate bill.
Does explaining the plan change what it covers?
No. Coverage is defined by the contract with the carrier, the plan documents and the summary of benefits and coverage. Better explanation does not alter coverage, but it helps employees choose well and make good use of the plan.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is where cost sharing begins; the out-of-pocket maximum caps what an employee pays over a year for covered, in-network care.
Ready? Send us your renewal, or talk it over with someone first. There is no charge and no commitment.
The material here is a general overview of group health plan terms and is not legal or tax advice. For plan-specific questions, consult your plan documents or the carrier directly.
Send us your renewal.
We will report whether it looks competitive, where we see opportunity, and which five questions we would raise with your carrier. It costs nothing and commits you to nothing.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, plus two more for groups of 50 or over. We ask for nothing beyond that, since each additional item only delays the review.
CFH is an independent employee benefits consulting firm that reviews the whole program: cost, plan performance, risk and administration.
Switch to CFH. Unhappy with your broker? Your employees won’t notice. You will. →
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