Appendix L: Plan and Group Definitions

Federal Government Plan (FGP)

A governmental plan established or maintained for its employees by the United States Government or by any agency or instrumentality of the government.

A.C.A. 23-86-303.13

Governmental Plan (GPL)

A plan established or maintained for its employees by the Government of the United States, by the government of any State or political subdivision thereof, or by any agency or instrumentality of any of the foregoing.

A.C.A. 23-86-303.14

Health Maintenance Organization (HMO)

(A) A federally qualified health maintenance organization as defined in section 1301(a) of the Public Health Service Act, 42 U.S.C. § 300e(a);

(B) An organization recognized under state law as a health maintenance organization; or

(C) A similar organization regulated under state law for solvency in the same manner and to the same extent as a health maintenance organization.

A.C.A. 23-86-303.20

Individual Market (IND)

The market for health insurance coverage offered to individuals other than in connection with a group health plan.

A.C.A. 23-86-303.22

Large Employer (LRG)

In connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least fifty-one (51) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year.

A.C.A. 23-86-303.24

Small Employer (SMG)

In connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least two (2) but not more than fifty (50) employees on business days during the preceding calendar year and who employs at least two (2) employees on the first day of the plan year.

A.C.A. 23-86-303.34

Small-Group Market (SMM)

The health insurance market under which individuals obtain health insurance coverage directly or through any arrangement on behalf of themselves and their dependents through a group health plan maintained by a small employer.

A.C.A. 23-86-303.35

Third-Party Administrator (TPA)

Any person, firm, or partnership that collects or charges premiums from or adjusts or settles claims on residents of this state in connection with life or accident and health coverage provided by a self-funded plan or a multiple employer trust or multiple employer welfare arrangement. "Third-party administrator" includes administrative-services-only contracts offered by insurers and health maintenance organizations but does not include the following persons:

(1) An employer, for its employees or for the employees of a subsidiary or affiliated corporation of the employer;

(2) A union, for its members;

(3) An insurer or health maintenance organization licensed to do business in this state;

(4) A creditor, for its debtors, regarding insurance covering a debt between them;

(5) A credit card-issuing company that advances for or collects premiums or charges from its credit card holders as long as that company does not adjust or settle claims;

(6) An individual who adjusts or settles claims in the normal course of his or her practice or employment and who does not collect charges or premiums in connection with life or accident and health coverage; or

(7) An agency licensed by the Insurance Commissioner and performing duties pursuant to an agency contract with an insurer authorized to do business in this state.

A.C.A. 23-92-201

Self-Funded Plans (SLF)

A self-insurance arrangement whereby an employer provides health or disability benefits to employees with its own funds.

The Arkansas Insurance Department has no regulatory authority over a self-funded plan because it is not an insurance policy. Complaints and grievances over a self-funded health plan would be handled by ERISA.

Administrative Services Only (ASO)