With the self-funded v. insured question looming large, the next question is where to look and what to look for to answer this all important question.  There are several places.  The first is the SPD (Summary Plan Description).  You will need to request this from the third party administrator handling the claim and/or directly from the Plan Administrator.

However, I have found that looking up the Form 5500 online is the fastest way to get an idea of how the Plan is funded.  The Form 5500 is a federal filing that must be filed annually by each employer maintaining an ERISA plan.  The fastest way to find this form is to register with www.freeerisa.com and search by employer name.  It is free.

Once you pull up the latest Form 5500 for the Plan, look at page 1, elements 9a (“plan funding arrangement”) and 9b (plan benefit arrangement”).  Each of these elements lists the following options:

(1)   Insurance;
(2)  Section 412(e)(3);
(3)   Trust;
(4)   General assets of the sponsor.

If boxes (3) and/or (4) are marked on both then the inquiry stops here because trusts and general assets of the sponsor exclude all policies of insurance and therefore are clearly fully self-funded Plans.  If one or more of the other two boxes are checked then the inquiry continues by turning to the schedules attached to Form 5500.

What you are looking for is Schedules A or C.  These schedules further detail the relationship between the payor of benefits and the Plan.  Confusion often lies in looking at the Form 5500 because large companies will have several benefits plans reported on the form and often times there will be multiple Schedule As and Cs attached to the Form 5500 (i.e. one for a dental plan; one for a vision plan; one for a life insurance plan etc.).  This leads to multiple funding arrangements being selected that describes the multiple plans.

So first you want to find the schedules that identify the health plan.  Look first for a Schedule A form for the health plan.  If you do not have a Schedule A for the health plan skip to the Schedule C discussed below.  If you have a Schedule A, here is what to look for on the schedule:  First, you should have a named insurance company under Part 1(a).  Next look at Part III(8).  There are multiple boxes that can be checked.  Box (8)(a) “Health” should be marked (again, tells you this is the health plan).  If any other box in section (8) is marked other than (i) “Stop Loss,” you are in luck and the plan is insured and state law applies.  If the Stop Loss box is checked, see below regarding stop loss issues.

If the benefit provider you are looking for is not on a Schedule A, it likely is on a Schedule C.  On Schedule C, you will see reference to “claims processing,” “contract administrator,” and “plan administrator.”  An insurer providing insurance would not be listed on a Schedule C and therefore is indicative of  a fully self-funded Plan.