Adding a hospital outside the United States to a self-funded plan: what the documents have to say
There is no special rule in the Employee Retirement Income Security Act for care obtained in another country. The instruments are the ordinary ones: a written plan, a summary a participant can understand, and a stop-loss contract.
Published November 7, 2026
8 min read
Information provided is for general reference only and does not constitute medical advice. Consult a qualified healthcare professional before making medical decisions.
Self-funded plan documents contain no special rule for a hospital outside the United States; we searched the statute and the regulation and found none. Three ordinary instruments govern instead: the written plan under 29 U.S.C. § 1102, a summary that must reflect the plan within 120 days of being disclosed, and a stop-loss contract the states regulate.
Sylk Health. Current as of October 2026.
A plan sponsor considering a hospital outside the United States generally starts by looking for the provision that governs it. The search comes back empty, and that is the useful finding. What governs is the machinery every self-funded plan already runs on. This post sets out what that machinery requires, quoted from the statute and the regulation. None of it is legal advice, and a sponsor with a decision to make should take it from counsel.
The three documents at a glance
The table below sets out the three instruments, the law each answers to, and who may change it.
Document
Governed by
What it must do
Who may change it
Written plan instrument
ERISA, 29 U.S.C. § 1102
Establish the plan, name fiduciaries, set an amendment procedure
Whoever the instrument names, by its own procedure
Summary plan description
29 U.S.C. § 1022 and 29 C.F.R. § 2520.102-3
Explain benefits and every condition on them; reflect the plan within 120 days of disclosure
The plan administrator, to match the plan
Stop-loss contract
State insurance law; NAIC Model Law #92 (1995)
Reimburse the sponsor for large claims on its own terms
Only the sponsor and the carrier together
Only the first two are ERISA documents. The third has a counterparty, which is why it behaves differently when anything changes.
Why is adding a foreign hospital a document question?
Adding any benefit is a document question, because a self-funded plan is whatever its written instrument says it is. The statute (opens in new tab) puts the foundation in one sentence: "Every employee benefit plan shall be established and maintained pursuant to a written instrument. Such instrument shall provide for one or more named fiduciaries who jointly or severally shall have authority to control and manage the operation and administration of the plan."
A benefit exists because the instrument says it exists. A network, a centre of excellence, a travel allowance or a waiver of cost sharing exists on the same terms. The statute then lists what the instrument must do, and two items bear on any change. Under section 1102(b)(2) it must "describe any procedure under the plan for the allocation of responsibilities for the operation and administration of the plan", and under section 1102(b)(3) it must "provide a procedure for amending such plan, and for identifying the persons who have authority to amend the plan".
A sponsor adding anything therefore has a prior question to answer: who, under this instrument, is permitted to amend it, and by what procedure. That is not a question about foreign care.
What must the summary plan description disclose?
The summary must disclose every condition that could take a benefit away, in terms the average participant can follow. A written plan is not the document participants read, and the summary plan description (opens in new tab) is held to comprehension rather than completeness. It "shall be written in a manner calculated to be understood by the average plan participant, and shall be sufficiently accurate and comprehensive to reasonably apprise such participants and beneficiaries of their rights and obligations under the plan."
The content regulation (opens in new tab) is a long list, and one item matters most to a benefit with conditions attached. The summary must contain "a statement clearly identifying circumstances which may result in disqualification, ineligibility, or denial, loss, forfeiture, suspension, offset, reduction, or recovery" of benefits a participant might otherwise reasonably expect.
Read against a new benefit with geographic, facility or procedural conditions, that provision is the operative one. The conditions have to be in the summary, not left in the plan document for a reader who will never see it.
What we searched for and did not find
The claim that there is no special rule is a negative one, so it deserves an account of the search rather than an assertion. We looked through the plan-document provisions, the summary plan description statute and the content regulation for any geographic limitation on where covered services may be furnished, or any provision addressed to care obtained outside the United States. A second reader repeated the search independently on the electronic Code of Federal Regulations. Neither found one.
The conclusion is narrow and should stay narrow. It means the statute and the content regulation do not single out foreign care. It does not mean nothing else does, and it says nothing about any other body of law a sponsor may be subject to.
Why is stop-loss outside ERISA?
Stop-loss is a contract between the plan sponsor and a carrier, not between the plan and a participant, and its regulation belongs to the states. The Department of Labor's Technical Release 2014-01 (opens in new tab) confirms the states' authority over it, and the model law (opens in new tab) the states work from is a state insurance instrument rather than a federal one.
That division has a practical consequence. A sponsor may amend its plan without asking anyone, because the amendment procedure is in its own instrument. It cannot amend its stop-loss contract that way, because the other party is an insurer. Anything that changes where or how a large claim might arise is a matter for that contract and for the carrier's notification requirements; our post on stop-loss and a hospital abroad sets out what can and cannot be established about it. We quote no carrier's policy wording here, because we have not opened one and an exclusion quoted from a summary is not an exclusion.
Frequently asked questions
How up to date must a summary plan description be?
The regulation sets a window. 29 C.F.R. § 2520.102-3 provides that "The summary plan description must accurately reflect the contents of the plans as of the date not earlier than 120 days prior to the date such summary plan description is disclosed." A plan amended to add a new benefit therefore needs a summary that catches up with it, or the summary stops describing the plan participants actually have.
Who regulates stop-loss insurance bought by a self-funded employer?
The states do. The National Association of Insurance Commissioners' 2015 white paper explains that the federal exemption for self-funded plans "does not extend to stop loss insurance policies purchased by self-funded employers, which are subject to state insurance regulation." The paper notes that federal guidance "specifically references NAIC Model #92 when it reiterates the states' authority to regulate stop loss insurance."
Is the employer still liable if the stop-loss carrier refuses a claim?
The employer remains liable. According to the same 2015 white paper, "A self-funded employer may transfer some of its risk of loss to a stop loss insurer by purchasing a stop loss insurance policy, but the employer remains ultimately responsible if the stop loss insurer fails to perform or denies a claim ..." The plan's promise to its participants does not depend on the carrier's promise to the sponsor.
What self-funded plan documents add up to
Self-funded plan documents work in a particular order:
The written instrument says what the benefit is and who may change it.
The summary tells participants, in language they can follow, what the benefit is and every condition that could take it away.
The stop-loss contract, governed by state law and held by a counterparty, determines what happens when a claim is large.
No part of that is specific to a hospital in another country, which is the point. The question the statute recognises is whether the instrument permits the amendment, whether the summary discloses the conditions, and whether the stop-loss carrier has been told. We supply a price and nothing else, so nothing in this post is a recommendation to add anything. It is an account of where the answer lives, and the answer belongs to counsel.
This article is general information about federal and state rules. It is not legal, tax or financial advice; consult counsel on any plan decision.
Disclosure: Sylk Health supplies procedure-price data and earns a commission from providers on bookings completed through its platform. It would benefit from broader use of externally benchmarked prices for medical procedures, and from any gap between those prices and prices in the United States.
United States Department of Labor, Employee Benefits Security Administration, Technical Release 2014-01 (opens in new tab), guidance on state regulation of stop-loss insurance.
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