How do I tell if my plan is self-funded ERISA or a Georgia-regulated insured plan?

· 3 min read

The single question that decides this is who actually pays the claims. In a self-funded plan, the employer bears the financial risk and pays medical claims out of its own funds, usually hiring an insurance company only to administer the paperwork. In an insured plan, the employer buys a policy and the insurance company takes the risk. Self-funded employer plans fall under the federal ERISA statute, while insured plans remain subject to Georgia insurance regulation, and that difference can change whether the made-whole doctrine protects an injury recovery.

Documents that reveal the answer

The plan paperwork usually contains the clues, though it can take some digging:

  • The Summary Plan Description (SPD). ERISA requires self-funded plans to provide one. Its presence, and its references to ERISA, is a strong signal.
  • The master plan document. Language stating the employer “self-funds” or pays benefits from its general assets points to a self-funded plan.
  • The insurance card or certificate. A card naming a true insurance policy, or a certificate of insurance, leans toward an insured plan, though an administrator’s logo alone is not decisive because administrators also service self-funded plans.
  • Form 5500. Larger employer plans file this annual report, which can indicate funding arrangement.

Because the administrator on the card is often a familiar insurance brand even when the plan is self-funded, the logo by itself proves little. Confirming who bears the risk is what matters.

Why government and individual coverage is different

Some coverage sits outside the ERISA-versus-insured split entirely. Government employer plans and church plans are generally exempt from ERISA. Coverage bought directly by an individual on the open market is not an employer plan at all and is regulated as Georgia insurance. Knowing the source of the coverage narrows the category before the funding question even comes up.

Why the classification matters

The label is not a technicality. A Georgia-regulated insured plan is subject to the state’s made-whole and common-fund protections, which can shrink or defeat reimbursement when the injured person was not fully compensated. A self-funded ERISA plan can enforce its written reimbursement terms over those state defaults. Misclassifying the plan can lead someone to pay back far more, or far less, than the law actually requires.

The bottom line

To classify a plan, look past the administrator’s name and find who carries the risk: employer-funded means self-funded ERISA, while a purchased policy means a Georgia-regulated insured plan. The SPD, master plan document, and funding language settle it, and the answer controls whether Georgia’s equitable protections apply.

This article is for general educational and informational purposes only and is not legal advice. It does not create an attorney-client relationship, and Georgia law may change. For advice about a specific situation, consult a licensed Georgia personal injury attorney.

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