COMMERCIAL EMPLOYER BASED INSURANCE PLANS

The information below only pertains to COMMERCIAL PLANS ONLY.

The information below is NOT applicable to any Federal (Medicare, Federal Government Employees Insurance Plans, or Tricare) or State (Managed Medicaid, Medicaid, or State Government Employees Insurance Plans) insurance benefits and/or plans. Federal and State fall under different federal and state regulations.

What is the Master Plan Document and Summary Plan Description

Why are these documents important?

What you’re about to read could directly impact your insurance coverage, your out-of-pocket costs, and whether or not we can fight for your claim. This information applies everywhere healthcare services are obtained.

At New Leaf Behavioral Health, PLLC, our commitment extends beyond providing exceptional care, we advocate for your right to receive the full benefits guaranteed under your insurance policy.

Crystal is a Certified Professional Biller and very passionate about ensuring patients are not left paying out-of-pocket for services their insurance is obligated to cover.

Unfortunately, many providers, billers, and practices are unaware of the laws that govern these benefits and therefore do not request essential documents such as the Master Plan Document (Plan Document) and/or Summary Plan Description (SPD). But we do, because we understand that without these documents, we cannot fully protect your interests.

Please be aware that HR departments often mistakenly provide the Summary of Benefits and Coverage (SBC) when asked for plan documents. While well-intentioned, the SBC is not the correct document for claims disputes, it lacks the legal detail required to challenge denials. What we need is the Summary Plan Description (SPD) and, ideally, the Master Plan Document, which outline your full rights and coverage terms under the plan.

Let's dig into the different documents and further explain what they are and their purpose.

Summary of Benefits and Coverage

The Summary of Benefits and Coverage (SBC) is a standardized, consumer-friendly document typically around 8 to 10 pages in length that provides a high-level overview of a health insurance plan’s key features. It outlines what the plan covers, what it costs (including copays, deductibles, and coinsurance), and includes coverage examples to help patients understand how the plan works in real-life scenarios. The SBC is meant to help individuals easily compare different insurance options and make informed decisions, but it is only a summary.

Summary Plan Description

In contrast, the Summary Plan Description (SPD) is a much more comprehensive document required under ERISA (Employee Retirement Income Security Act). It goes into extensive detail about the plan's structure, benefits, participant rights, and the procedures for filing claims and appeals. It often spans 50 pages or more and serves as the primary reference for understanding the full scope of what is and isn't covered.

The Master Plan Document or Plan Document

Even more detailed than the SPD is the Master Plan Document (MPD) (sometimes referred to simply as the Plan Document). This is the formal, legally binding contract between the plan sponsor (usually the employer) and the insurance provider or administrator. It outlines all provisions, terms, conditions, limitations, and the precise legal language governing the health plan. In the event of a dispute, the Master Plan Document is the ultimate authority on what the plan does and does not cover.

Brief Summary of the Three Different Documents

In short: the SBC offers a basic snapshot, the SPD provides the in-depth guide, and the Master Plan Document is the full legal contract governing the plan. All three are important, but only the SPD and Master Plan Document contain the necessary information to challenge denials and hold the insurance accountable.

We will get into further details below on these documents.

Real World Example of The Master Plan and Summary Plan Description Documents

Let me give you a real-world example that underscores the importance of having these documents on hand.

A patient was evaluated in our clinic, and we submitted the claim to the insurance company using valid, covered CPT (Current Procedural Terminology) codes. Despite the fact that these codes were covered under the patient’s plan, the insurance company denied part of the claim, stating that the services were not covered and shifting the financial burden to the patient.

Fortunately, I had a copy of the patient’s Master Plan Document and SPD, which clearly showed no exclusion for the billed services. I also reviewed the insurer’s public materials and verified that the CPT codes were covered.

Armed with this documentation, I appealed the denial and escalated the issue to the Department of Labor’s Employee Benefits Security Administration (EBSA). After pressure and regulatory oversight, the insurance company reversed their denial and labeled the issue a “system error.”

In truth, this was not a system error, it was a planned denial. Insurers often rely on such denials in the hopes that patients and providers will not fight back, allowing them to retain funds that should have been paid out for care. These tactics are harmful, unethical, and when we have the documentation, we can stop them.

What is Employee Retirement Income Security Act (ERISA) of 1974?

The Employee Retirement Income Security Act of 1974 (ERISA) is a federal law that sets standards for most voluntarily established retirement and health plans in private industry. Its purpose is to protect plan participants and beneficiaries by requiring transparency, fiduciary responsibility, and accountability from plan administrators. ERISA ensures that employees receive the benefits promised by their employers and gives them the right to sue for benefits and breaches of fiduciary duty.

Under federal law, the Employee Retirement Income Security Act (ERISA) of 1974, employers who provide medical insurance or other employee benefits must establish an “employee welfare benefit plan” and comply with ERISA requirements. This includes maintaining a written plan document and providing a Summary Plan Description. These rules apply regardless of employer size or funding method (employer-paid or employee-paid), with the exception of government or church plans, which are exempt from ERISA. The SPD and Master Plan Document outline the terms of your benefits, eligibility requirements, costs, claim procedures, appeal rights, and other crucial information. These documents must be written in plain language that the average plan participant can understand.

Let's Further Dive Into The Master Plan Document or Plan Document and Summary Plan Description

We want to take a moment to discuss the importance of the Master Plan Document or Plan Document which is the comprehensive written instrument describing the operation and administration of an employer's plan. The plan document is written in legalese and may be difficult for the average participant to read and understand. Section 402 of ERISA requires that benefits plans subject to the regulations must be established and maintained according to a written instrument. The written plan document must clearly identify certain basic information about the plan, including the following:

• The named fiduciary who will have the authority and responsibility to administer the plan.
• Procedures for amending and terminating the plan.
• The source of plan contributions.
• The allocation of responsibilities for the operation of the plan between the employer and the insurance carrier or third-party administrator.

The plan document tells the plan participants about the benefits they are entitled to under the plan and provides guidelines to be used by the plan administrator in decision-making when it comes to plan operations. It is not required to be distributed to the participants unless requested.

Summary Plan Description (SPD) for your insurance coverage. The SPD is a document that outlines your benefits, rights, and responsibilities under your insurance plan. It is a crucial tool in ensuring that your insurance company is following the contractual agreement you have with them.

The summary plan description (SPD) is simply a summary of the plan document required to be written in such a way that the participants of the benefits plan can easily understand it. Unlike the plan document, the SPD is required to be distributed to plan participants. ERISA provides specific guidelines regarding the required content of the SPD and the required style and format. In effect, because the SPD is summarizing the plan document, the plan document must encompass the content required for the SPD.

Plan amendments must be made to both documents. The Master Plan Document or Plan document provides more detail than the SPD and should be referred to when administering the plan.

Confusion often arises for employers with fully insured plans as the insurance carrier does not provide the ERISA Master Plan Document or Plan document or the SPD. This is the responsibility of the plan administrator. The insurance carriers typically provide employers with a master contract, certificate of coverage or summary of benefits, and employers may mistakenly assume this meets the ERISA requirement. These insurance-provided documents contain some, but not all of the content required under ERISA. Therefore, in practice, "wrap" documents are combined with the insurance-provided documents to meet the ERISA requirements. This means the employers will "wrap" the insurance documents with another document containing the missing content required under ERISA.

Let's Talk More About ERISA

As a patient or plan member, you have protected rights under Title 29 USC §2560.503-1(b)(3) and Title 29 USC §2590.715-2719, which entitle you to a true and accurate understanding of your healthcare coverage, including any limitations or exclusions. These statutes support your right to receive a copy of your plan’s governing documents, including any updates or amendments, deductible and co-insurance details, subrogation policies, coordination of benefits clauses, claim handling procedures, and financial arrangements with third-party vendors involved in the processing of your benefits.

Under ERISA (Employee Retirement Income Security Act of 1974), specifically 29 U.S. Code § 1024(b)(4), employees and plan participants have the legal right to request and receive copies of important plan documents from the plan administrator, including the Summary Plan Description (SPD) and the Master Plan Document.

29 U.S.C. § 1024(b)(4): “The administrator shall, upon written request of any participant or beneficiary, furnish a copy of the latest updated summary plan description, and the latest annual report, any terminal report, the bargaining agreement, trust agreement, contract, or other instruments under which the plan is established or operated.”

This means that you are entitled to receive these documents within 30 days of your written request, and failure to provide them may result in penalties of up to $110 per day (per request) enforced by the U.S. Department of Labor.

Claims

When you receive healthcare services, our office submits claims as a courtesy to you.

Those claims belong to you and the financial responsibility for those claims ultimately rests with you.

Insurance companies often deny covered services, misrepresent plan terms, or issue denials under the pretense of medical necessity or prior authorization requirements that do not actually apply under your plan.

Having the Master Plan Document and SPD allows us to challenge those denials, escalate to the appropriate federal entities if necessary, and ensure that your insurance provider upholds their legal and contractual responsibilities.

As the insured, you are entitled to request a complete, unredacted copy of any Administrative Services Only (ASO) agreements, recovery and repricing contracts, or third-party vendor relationships that influence how your claims are handled and paid. If an insurer or plan administrator engages in any adverse handling of your claim including the withholding of entitled benefits, application of conflicting interests, or failure to apply ERISA-compliant procedures you may file a complaint with the Department of Labor and seek corrective action.

Why This is Important?

We cannot emphasize this enough: if you do not provide the Master Plan Document and SPD, we cannot fight for your benefits. Without these documents, we are unable to appeal claim denials or challenge inaccurate benefit determinations.

If we do not have the necessary documents and a denial is issued, you will be responsible for the unpaid balance.

Each insurance plan differs depending on the employer and the structure of the benefits offered. Even two patients with the same insurance carrier may have completely different benefit structures and exclusions. We cannot fight blindly.

To protect yourself and ensure your care is properly reimbursed, please obtain a complete copy of the Master Plan Document and Summary Plan Description from your employer’s HR department and/or HR Benefits department. We cannot request this on your behalf; it must come from you or the primary subscriber.

We are committed to protecting your health and your finances and that means demanding insurance companies do what you pay them to do. By providing these documents, you are empowering us to advocate effectively for your rights and financial protection.

What If I DO NOT Provide the Requested Documents?

Please be advised that if you choose NOT to provide your Master Plan Document and Summary Plan Description as requested, and your insurance company denies a claim, our office will not be able to appeal or fight the denial on your behalf.

Our office will not alter procedure codes or documentation at the direction of insurance representatives. Often, the individuals you speak with are customer service agents who are not certified coders and are unfamiliar with the specifics of the services provided.

Requests or demands to change codes to facilitate payment may constitute insurance fraud, which we take very seriously and will not engage in under any circumstances.

Do not contact our office stating that “the insurance company says to bill it this way” in order to get paid. This is not an appropriate or legitimate approach to medical billing.

Please be aware that insurance companies may and often do provide misleading information in order to quickly end calls and give the impression that they are assisting you.

We are committed to ethical and accurate billing practices, and we appreciate your understanding and cooperation.

Please understand we will not be contacting the insurance company to appeal or fight the denial. Without these critical documents, we have no supporting evidence to challenge the decision because ultimately, this is your insurance plan, and the claim belongs to you.

In these cases, you will be responsible for paying out-of-pocket and you will be solely responsible for pursuing reimbursement directly with your insurance provider.

What If I DO Provide the Requested Documents?

However, if you DO provide the necessary documents, we will aggressively fight on your behalf to secure the reimbursement you are entitled to. We cannot fight blindly, going into battle without your gear is not only unwise, but also ineffective.

Help us help you!

What is the purpose behind requesting these documents? Why are you the only practice that requests these documents? Is this some type of scam? Are you getting some type of kick back from this?

At our office, we request the Master Plan Document (MPD) and Summary Plan Description (SPD) because they are the cornerstone of understanding your health benefits under federal law, specifically, the Employee Retirement Income Security Act (ERISA).

While most healthcare providers don’t ask for these documents and it may seem unusual, especially if other healthcare providers don’t ask for them; that’s precisely the problem. We ask for them because we believe in going beyond the surface to protect your financial and medical interests.

These documents define the exact rules your health plan must follow, and they provide the legal basis for challenging unfair denials or incomplete reimbursements.

Unfortunately, the vast majority of billers, healthcare providers, and medical offices either don't even know this law exists, let alone don’t know how to apply it, and use it effectively. We do, and we leverage it to protect you.

We are different because we choose to do what’s right, not what’s common.

People already pay a significant amount for their health insurance, and yet too often, patients are left footing bills they shouldn't be responsible for. It is essential to hold insurers accountable to administer those benefits exactly as promised.

When no one holds them accountable and challenges the system, insurance companies continue to deny or underpay claims unchecked, pocketing the savings which means more of your money stays in the pockets of the insurance companies. Insurance companies inflate their profits, reward shareholders and executives with bigger bonuses while patients and providers are left paying more and receiving less.

Our approach is about accountability and fairness, taking this extra step holding insurers to the promises they make in writing to protect you financially. It is the right thing to do.

Wouldn't you rather pay the least amount possible for the services you’re already paying premiums for?

Don’t you want to get the most bang for your buck?

You deserve transparency, fairness, and advocacy. We are committed to providing that.

We’re Not Crazy. We’re Just Unusually Obsessed with Beating Insurance at Their Own Game and We Shine a Flashlight Into the Darkest Corners of Your Health Plan

We hear that a lot “You guys are crazy. Why do you even do this?” And honestly? It’s a fair question.

Well, buckle up, because this isn’t your average healthcare office and we’re not here to play patty-cake with insurance companies. While other providers are busy printing outdated brochures and waiting on hold for three hours, we’re deep-diving into the Matrix of your insurance plan wearing metaphorical night-vision goggles and fueled by equal parts caffeine and righteous fury. Let's dive in and further explain.

We get it, on the surface, it might seem a little crazy that we go to such lengths when most other providers don’t making us look a little extra.

The truth is, most people have no idea what they’re really entitled to under their health plan. Insurance companies count on that. They know very few providers will challenge them.

What’s in it for us? Not fame (though we wouldn’t say no to a trophy that says “Insurance Plan Decoder Champions 2025”). It isn't bonuses as we don't get a dime more for going the extra mile. What we do get is peace of mind knowing we've actually protected our patients and what should be in it for everyone; doing right by our patients with the satisfaction of knowing we did the right thing. We further get satisfaction of knowing that we helped you avoid paying hundreds or thousands for something your insurance already promised to cover.

When we request documents like the Master Plan Document (MPD) and Summary Plan Description (SPD), we’re not doing it to make things harder, we’re doing it to make sure you’re not paying more than you should.

Why is this so important? Integrity. Advocacy. Trust. We don’t get kickbacks, bonuses, or incentives from insurance companies. Of knowing we protected our patients from paying thousands they didn’t owe. Of knowing we held an insurance company accountable to the rules they wrote.

In fact, the extra time and work it takes to go after these documents and hold insurers accountable costs us time and resources.

But we do it because we believe you deserve better. You’ve already paid for your coverage through premiums, you shouldn’t be overpaying again just because no one else wants to deal with the fine print.

So while others may overlook these rights or not even know they exist, we step up.

Because someone has to.

And because when we save you money, protect your benefits, and help you fight for what’s legally yours, that’s a win for everyone but the insurance companies. And we’re okay with that.

We do this because it matters.

Crazy? So yeah, maybe we are a little crazy. Crazy enough to care. Crazy enough to fight for what you’re owed. And crazy enough to believe that doing the right thing is still worth it. But if “crazy” means holding billion-dollar insurance companies accountable with their own fine print then we’re proudly nuts. Because we’d rather be the office that asks too many questions than the one that lets you quietly overpay while shareholders and CEOs cash bonus checks. Not doing this, just going along with whatever the insurance company decides, is even crazier.

Because if being a little unhinged is what it takes to stop you from getting ripped off? Then pass us another highlighter, we’re just getting started.

We do it because we can’t not do it. It's in our DNA. We're justice-fueled, patient-protecting, fine-print-reading maniacs and proud of it. We’re a little “extra.” But when your hard-earned money is on the line, wouldn’t you want someone who is?