Fully Insured Plan Third Party Claim
Fully Insured Plan Third Party Claim is not a national pay-order. 29 U.S.C. § 1144 lists the insurance savings clause and that a plan shall not be deemed an insurance company. HealthCare.gov lists a fully insured plan as purchased from an insurance company; KFF states that fully-insured employers buy coverage from a state-regulated insurer.
Last updated: September 9, 2026
Fully Insured Plan Third Party Claim
29 U.S.C. § 1144 lists preemption, the insurance savings clause, and the deemer rule. HealthCare.gov, UMich, AHP, KFF, and NAIC list the fully insured versus self-funded funding fork. Cornell WEX lists general subrogation vocabulary. North Carolina G.S. 44-49 / 44-50 rows are competing hospital-lien law on the same pot.
| Claim | Listed | Source |
|---|---|---|
| ERISA express preemption of state laws relating to employee benefit plans | “shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan” | 29 U.S.C. § 1144 |
| Insurance savings clause (state laws regulating insurance survive) | “nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State which regulates insurance, banking, or securities” | 29 U.S.C. § 1144 |
| Deemer clause — plan not deemed an insurer | “shall be deemed to be an insurance company or other insurer, bank, trust company, or investment company” | 29 U.S.C. § 1144 |
| Deemer applies to employee benefit plan described in §1003(a) | “Neither an employee benefit plan described in section 1003(a) of this title” | 29 U.S.C. § 1144 |
| HealthCare.gov: fully insured job-based plan definition | “A health plan purchased by an employer from an insurance company.” | HealthCare.gov fully insured |
| HealthCare.gov: self-insured plan = employer pays claims | “the employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims” | HealthCare.gov self-insured |
| UMich: fully-insured = fixed premium to commercial insurer | “A fully-insured health plan is a traditional, group-health insurance policy where an employer pays a fixed, annual premium to a commercial insurer” | UMich health-plan definitions |
| UMich: insurer bears all financial risk on fully-insured | “The insurer bears all financial risk” | UMich health-plan definitions |
| UMich: self-insured employer pays medical claims | “the employer itself collects premiums from enrollees and takes the responsibility of paying employees’ and dependents’ medical claims” | UMich health-plan definitions |
| AHP glossary: fully-insured premiums to third-party insurer who assumes claim risk | “A full-insured plan is a health plan where premiums are paid to a third party insurance firm and that firm operates the health plan and assumes the risks associated with the enrollees’ medical claims” | AHP fully-insured glossary |
| KFF: self-funded = employer pays claims directly | “the employer pays enrollees’ medical claims directly” | KFF self-funded FAQ |
| KFF: fully-insured = buys from state-regulated insurer | “where the employer buys coverage from a state-regulated insurance company” | KFF self-funded FAQ |
| KFF: self-funded largely not required to comply with state insurance laws | “unlike fully-insured plans, self-funded coverage provided by private employers is largely not required to comply with state insurance laws” | KFF self-funded FAQ |
| NAIC: ERISA does not preempt state insurance laws | “ERISA, however, does not preempt state insurance laws” | NAIC ERISA topic |
| NAIC: self-funded exempt from state regulation | “pays directly out of plan assets (a “self-funded plan”), it is exempt from state regulation” | NAIC ERISA topic |
| NAIC: insured plan purchases insurance (state regulates contract) | “purchases insurance to cover some or all of its benefit obligations (an “insured plan”)” | NAIC ERISA topic |
| NAIC dual regulatory framework | “The result is a dual regulatory framework” | NAIC ERISA topic |
| NAIC saving clause allows state insurance laws | “this is balanced by the “saving clause,” which allows states to enforce laws that regulate insurance, banking, or securities” | NAIC ERISA topic |
| NAIC deemer clause limits treating self-funded plans as insurers | “The “deemer clause” further limits state authority by preventing states from treating self-funded ERISA plans as insurers” | NAIC ERISA topic |
| Cornell WEX: subrogation = one party assumes legal rights of another | “Subrogation is the process where one party assumes the legal rights of another” | Cornell WEX subrogation |
| Cornell WEX: insurer may be subrogated after compensating policyholder | “when an insurance company compensates a policyholder for an injury , the policyholder's right to sue the person responsible for the harm may be subrogated” | Cornell WEX subrogation |
| NC lien attaches to settlement funds | “A lien as provided under G.S. 44-49 shall also attach upon all funds paid to any person in compensation for or settlement of the injuries, whether in litigation or otherwise” | G.S. 44-50 |
| NC attorney's fees not interfered with | “Nothing in this section or in G.S. 44-49 shall be construed so as to interfere with any amount due for attorney's services” | G.S. 44-50 |
| NC provider lien cap 50% exclusive of attorneys' fees | “The lien provided for shall in no case, exclusive of attorneys' fees, exceed fifty percent (50%) of the amount of damages recovered” | G.S. 44-50 |
| NC hospital/provider lien created on PI recoveries | “there is hereby created a lien upon any sums recovered as damages for personal injury in any civil action in this State” | G.S. 44-49 |
Sources fetched September 9, 2026: 29 U.S.C. § 1144, HealthCare.gov fully insured, HealthCare.gov self-insured, UMich health-plan definitions, AHP fully-insured glossary, KFF self-funded FAQ, NAIC ERISA topic, Cornell WEX subrogation, G.S. 44-50, G.S. 44-49.
Frequently asked questions
What is a Fully Insured Plan Third Party Claim?
Fully Insured Plan Third Party Claim is the recovery path when a fully insured health plan seeks reimbursement from a third-party settlement. 29 U.S.C. § 1144 lists the insurance savings clause and that a plan shall not be deemed an insurance company. HealthCare.gov lists a fully insured plan as purchased from an insurance company. KFF and NAIC state that fully insured plans buy state-regulated insurance while self-funded plans pay claims from plan assets.
What does 29 U.S.C. § 1144 say about the savings and deemer clauses?
29 U.S.C. § 1144 states that nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State which regulates insurance, banking, or securities. It also states that neither an employee benefit plan described in section 1003(a) shall be deemed to be an insurance company or other insurer. Those are the published savings and deemer rules.
How do HealthCare.gov, UMich, and KFF define a fully insured plan?
HealthCare.gov lists a fully insured job-based plan as a health plan purchased by an employer from an insurance company. UMich states that a fully-insured health plan is a traditional group-health insurance policy where an employer pays a fixed annual premium to a commercial insurer and the insurer bears all financial risk. KFF states that fully insured coverage is where the employer buys coverage from a state-regulated insurance company.
What dual regulatory framework does NAIC list?
NAIC states that ERISA does not preempt state insurance laws. If a plan purchases insurance to cover some or all of its benefit obligations (an “insured plan”), state insurance regulation applies to the contract; if it pays directly out of plan assets (a “self-funded plan”), it is exempt from state regulation. NAIC states that the result is a dual regulatory framework.
Do competing G.S. 44-50 hospital liens disappear under fully insured status?
No. North Carolina G.S. 44-49 states that there is hereby created a lien upon any sums recovered as damages for personal injury. G.S. 44-50 states that the lien shall in no case, exclusive of attorneys' fees, exceed fifty percent (50%) of the amount of damages recovered. Those are competing published rules beside the fully insured funding fork.