§300gg–91 — Title 42 The Public Health and Welfare | U.S. Code

Summary

Defines the words used in this part of the health law and explains what kinds of plans and coverage the rules apply to. Group health plan: an employer-run benefit plan that gives medical care to workers or their dependents, either directly or by buying insurance or paying reimbursements; it normally does not include a qualified small employer health reimbursement arrangement except when Medicare Part C rules apply. Medical care: care for diagnosing, treating, preventing, or affecting the body’s structure or function, plus transportation that is mainly needed for that care, and insurance that pays for those things. Health insurance coverage: medical benefits sold by an insurer, HMO, or similar company. Health insurance issuer: an insurer licensed and regulated by a State (not a group health plan). Health maintenance organization (HMO): a federally qualified HMO, a State-recognized HMO, or a similar State-regulated organization. Group health insurance coverage: insurance tied to a group health plan. Individual health insurance coverage: insurance sold to people in the individual market, but not short-term limited duration insurance. Excepted benefits: certain types of limited coverage that are not treated as main health plans, such as accident or disability income, liability supplements, workers’ compensation, auto medical payments, credit-only, on-site clinic care, limited dental or vision, long-term care and home health, specified disease plans, hospital or fixed indemnity plans, and supplemental Medicare or military coverage. Other defined terms in one line each: Applicable State authority: the State insurance official who enforces these rules. Beneficiary/participant/plan sponsor/employee/employer: mean the usual ERISA definitions, with employer limited to those with two or more employees. Bona fide association: an association in existence at least 5 years, formed for reasons other than getting insurance, open to members without health-status limits, and meeting other State rules. COBRA continuation provision: section 4980B of title 26 (except subsection (f)(1) for pediatric vaccines), Part 6 of subtitle B of ERISA (except section 609), and Subchapter XX of this chapter. Church plan, governmental plan (Federal vs non‑Federal), health status‑related factor, network plan, adoption placement, State (includes territories), family member, genetic information (includes family tests and services but not sex or age), genetic test and genetic services, underwriting purposes (eligibility, premiums, pre‑existing exclusions, and related contract activities), qualified health plan, Exchange, individual market, large employer (average at least 51 employees last year and at least 2 on first day of plan year), small employer (average 1–50 employees last year and at least 1 on first day), large/small group markets, rules treating related employers as one, and a State option to treat 1–100 employees as small.

Title 42, §300gg–91

The Public Health and Welfare — Source: USLM XML via OLRC

(a)(1)The term “group health plan” means an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(1)]) to the extent that the plan provides medical care (as defined in paragraph (2)) and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Except for purposes of part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.), such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26).

(2)The term “medical care” means amounts paid for—

(A)the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body,

(B)amounts paid for transportation primarily for and essential to medical care referred to in subparagraph (A), and

(C)amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B).

(3)A program under which creditable coverage described in subparagraph (C), (D), (E), or (F) of section 2701(c)(1) 11 See References in Text note below. is provided shall be treated as a group health plan for purposes of applying section 2701(e).1

(b)(1)The term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer.

(2)The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in paragraph (3)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1144(b)(2)]). Such term does not include a group health plan.

(3)The term “health maintenance organization” means—

(A)a Federally qualified health maintenance organization (as defined in section 300e(a) of this title),

(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 such a health maintenance organization.

(4)The term “group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan.

(5)The term “individual health insurance coverage” means health insurance coverage offered to individuals in the individual market, but does not include short-term limited duration insurance.

(c)For purposes of this subchapter, the term “excepted benefits” means benefits under one or more (or any combination thereof) of the following:

(1)(A)Coverage only for accident, or disability income insurance, or any combination thereof.

(B)Coverage issued as a supplement to liability insurance.

(C)Liability insurance, including general liability insurance and automobile liability insurance.

(D)Workers’ compensation or similar insurance.

(E)Automobile medical payment insurance.

(F)Credit-only insurance.

(G)Coverage for on-site medical clinics.

(H)Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(2)(A)Limited scope dental or vision benefits.

(B)Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.

(C)Such other similar, limited benefits as are specified in regulations.

(3)(A)Coverage only for a specified disease or illness.

(B)Hospital indemnity or other fixed indemnity insurance.

(4)Medicare supplemental health insurance (as defined under section 1395ss(g)(1) of this title), coverage supplemental to the coverage provided under chapter 55 of title 10, and similar supplemental coverage provided to coverage under a group health plan.

(d)(1)The term “applicable State authority” means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this subchapter for the State involved with respect to such issuer.

(2)The term “beneficiary” has the meaning given such term under section 3(8) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(8)].

(3)The term “bona fide association” means, with respect to health insurance coverage offered in a State, an association which—

(A)has been actively in existence for at least 5 years;

(B)has been formed and maintained in good faith for purposes other than obtaining insurance;

(C)does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee);

(D)makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member);

(E)does not make health insurance coverage offered through the association available other than in connection with a member of the association; and

(F)meets such additional requirements as may be imposed under State law.

(4)The term “COBRA continuation provision” means any of the following:

(A)Section 4980B of title 26, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.

(B)Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1161 et seq.], other than section 609 of such Act [29 U.S.C. 1169].

(C)Subchapter XX of this chapter.

(5)The term “employee” has the meaning given such term under section 3(6) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(6)].

(6)The term “employer” has the meaning given such term under section 3(5) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(5)], except that such term shall include only employers of two or more employees.

(7)The term “church plan” has the meaning given such term under section 3(33) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(33)].

(8)(A)The term “governmental plan” has the meaning given such term under section 3(32) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(32)] and any Federal governmental plan.

(B)The term “Federal governmental plan” means a governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of such Government.

(C)The term “non-Federal governmental plan” means a governmental plan that is not a Federal governmental plan.

(9)The term “health status-related factor” means any of the factors described in section 2702(a)(1).1

(10)The term “network plan” means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care (including items and services paid for as medical care) are provided, in whole or in part, through a defined set of providers under contract with the issuer.

(11)The term “participant” has the meaning given such term under section 3(7) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(7)].

(12)The term “placement”, or being “placed”, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement with such person terminates upon the termination of such legal obligation.

(13)The term “plan sponsor” has the meaning given such term under section 3(16)(B) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1002(16)(B)].

(14)The term “State” means each of the several States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

(15)The term “family member” means, with respect to any individual—

(A)a dependent (as such term is used for purposes of section 2701(f)(2)) 1 of such individual; and

(B)any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual or of an individual described in subparagraph (A).

(16)(A)The term “genetic information” means, with respect to any individual, information about—

(i)such individual’s genetic tests,

(ii)the genetic tests of family members of such individual, and

(iii)the manifestation of a disease or disorder in family members of such individual.

(B)Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual.

(C)The term “genetic information” shall not include information about the sex or age of any individual.

(17)(A)The term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes.

(B)The term “genetic test” does not mean—

(i)an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes; or

(ii)an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved.

(18)The term “genetic services” means—

(A)a genetic test;

(B)genetic counseling (including obtaining, interpreting, or assessing genetic information); or

(C)genetic education.

(19)The term “underwriting purposes” means, with respect to any group health plan, or health insurance coverage offered in connection with a group health plan—

(A)rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the plan or coverage;

(B)the computation of premium or contribution amounts under the plan or coverage;

(C)the application of any pre-existing condition exclusion under the plan or coverage; and

(D)other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

(20)The term “qualified health plan” has the meaning given such term in section 18021(a) of this title.

(21)The term “Exchange” means an American Health Benefit Exchange established under section 18031 of this title.

(e)For purposes of this subchapter:

(1)(A)The term “individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.

(B)(i)Subject to clause (ii), such terms 22 So in original. Probably should be “term”. includes coverage offered in connection with a group health plan that has fewer than two participants as current employees on the first day of the plan year.

(ii)Clause (i) shall not apply in the case of a State that elects to regulate the coverage described in such clause as coverage in the small group market.

(2)The term “large employer” means, 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 51 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.

(3)The term “large group market” means 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 large employer.

(4)The term “small employer” means, 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 1 but not more than 50 employees on business days during the preceding calendar year and who employs at least 1 employees 33 So in original. on the first day of the plan year.

(5)The term “small group market” means 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.

(6)For purposes of this subsection—

(A)all 44 So in original. Probably should be capitalized. persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of title 26 shall be treated as 1 employer.

(B)In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.

(C)Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.

(7)Notwithstanding paragraphs (2) and (4), nothing in this section shall prevent a State from applying this subsection by treating as a small employer, with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsec. (a)(1), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Part C of title XI of the Act is classified generally to part C (§ 1320d et seq.) of subchapter XI of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables. section 2701, referred to in subsecs. (a)(3) and (d)(15)(A), is a reference to section 2701 of act

July 1, 1944. section 2701, which was classified to section 300gg of this title, was renumbered section 2704, effective for plan years beginning on or after Jan. 1, 2014, with certain exceptions, and amended, by Pub. L. 111–148, title I, §§ 1201(2), 1563(c)(1), formerly § 1562(c)(1), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 154, 264, 911, and was transferred to section 300gg–3 of this title. A new section 2701 of act

July 1, 1944, related to fair health insurance premiums, was added, effective for plan years beginning on or after Jan. 1, 2014, and amended, by Pub. L. 111–148, title I, § 1201(4), title X, § 10103(a), Mar. 23, 2010, 124 Stat. 155, 892, and is classified to section 300gg of this title. The Employee Retirement Income Security Act of 1974, referred to in subsec. (d)(4)(B), is Pub. L. 93–406, Sept. 2, 1974, 88 Stat. 829. Part 6 of subtitle B of title I of the Act is classified generally to part 6 (§ 1161 et seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor. For complete classification of this Act to the Code, see

Short Title

note set out under section 1001 of Title 29 and Tables. section 2702, referred to in subsec. (d)(9), is a reference to section 2702 of act July 1, 1944. section 2702, which was classified to section 300gg–1 of this title, was amended by Pub. L. 111–148, title I, § 1201(3), Mar. 23, 2010, 124 Stat. 154, and was transferred to subsecs. (b) to (f) of section 300gg–4 of this title, effective for plan years beginning on or after Jan. 1, 2014. A new section 2702, related to guaranteed availability of coverage, was added by Pub. L. 111–148, title I, § 1201(4), Mar. 23, 2010, 124 Stat. 156, effective for plan years beginning on or after Jan. 1, 2014, and is classified to section 300gg–1 of this title.

Amendments

2016—Subsec. (a)(1). Pub. L. 114–255 inserted at end “Except for purposes of part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.), such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26).” 2015—Subsec. (e)(2). Pub. L. 114–60, § 2(b)(1), substituted “51” for “101”. Subsec. (e)(4). Pub. L. 114–60, § 2(b)(2), substituted “50” for “100”. Subsec. (e)(7). Pub. L. 114–60, § 2(b)(3), added par. (7). 2010—Subsec. (d)(20), (21). Pub. L. 111–148, § 1563(b), formerly § 1562(b), as renumbered by Pub. L. 111–148, § 10107(b)(1), added pars. (20) and (21). Subsec. (e)(2). Pub. L. 111–148, § 1563(c)(16)(A), formerly § 1562(c)(16)(A), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “101” for “51”. Subsec. (e)(4). Pub. L. 111–148, § 1563(c)(16)(B), formerly § 1562(c)(16)(B), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “100” for “50” and “at least 1” for “at least 2” in two places. 2008—Subsec. (d)(15) to (19). Pub. L. 110–233 added pars. (15) to (19).

Statutory Notes and Related Subsidiaries

Effective Date

of 2016 AmendmentAmendment by Pub. L. 114–255 applicable to plan years beginning after Dec. 31, 2016, see section 18001(c)(3) of Pub. L. 114–255, set out as a note under section 300bb–8 of this title.

Effective Date

of 2008 AmendmentAmendment by Pub. L. 110–233 applicable, with respect to group health plans and health insurance coverage offered in connection with group health plans, for plan years beginning after the date that is one year after

May 21, 2008, and, with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market, after the date that is one year after

May 21, 2008, see section 102(d)(2) of Pub. L. 110–233, set out as a note under section 300gg–21 of this title.

§300gg–91 Definitions

Summary

Title 42, §300gg–91

Notes & Related Subsidiaries

Editorial Notes

References in Text

Short Title

Amendments

Statutory Notes and Related Subsidiaries

Effective Date

Effective Date

Citations & Metadata