§9802 — Title 26 Internal Revenue Code | U.S. Code

Summary

Group health plans must not use a person’s health or health history to decide who can sign up or stay enrolled. That includes current health, past illnesses, claims history, care they get, genetic information, disability, or proof about their ability to get insurance (including issues from domestic violence). Rules about waiting periods count as part of eligibility. Plans do not have to cover services they did not promise, and they can set limits or levels of benefits for people in the same situation. Plans also may offer discounts or lower copays for health programs. Plans cannot charge a higher premium to someone in the same group for those health reasons. They may not ask or force people or family members to take genetic tests, though a health care provider can ask a patient to get tested. Plans may use genetic test results only to decide payment and must ask for the smallest amount of information needed. A plan may ask (but not require) genetic testing for approved research if it is voluntary, does not affect coverage or premiums, is not used for underwriting, and the plan tells the Secretary and follows extra rules. Plans may not get genetic information for underwriting or before someone enrolls, except if it is picked up incidentally and not used for underwriting. A church plan can require proof of good health for employees of an employer with 10 or less employees or for people who enroll after the first 90 days of eligibility. Genetic information also covers a fetus carried by a pregnant woman and an embryo held under assisted reproductive technology.

Title 26, §9802

Internal Revenue Code — Source: USLM XML via OLRC

(a)(1)Subject to paragraph (2), a group health plan may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following factors in relation to the individual or a dependent of the individual:

(A)Health status.

(B)Medical condition (including both physical and mental illnesses).

(C)Claims experience.

(D)Receipt of health care.

(E)Medical history.

(F)Genetic information.

(G)Evidence of insurability (including conditions arising out of acts of domestic violence).

(H)Disability.

(2)To the extent consistent with section 9801, paragraph (1) shall not be construed—

(A)to require a group health plan to provide particular benefits (or benefits with respect to a specific procedure, treatment, or service) other than those provided under the terms of such plan; or

(B)to prevent such a plan from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.

(3)For purposes of paragraph (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for such enrollment.

(b)(1)A group health plan may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a similarly situated individual enrolled in the plan on the basis of any factor described in subsection (a)(1) in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.

(2)Nothing in paragraph (1) shall be construed—

(A)to restrict the amount that an employer may be charged for coverage under a group health plan except as provided in paragraph (3); or

(B)to prevent a group health plan from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

(3)(A)For purposes of this section, a group health plan may not adjust premium or contribution amounts for the group covered under such plan on the basis of genetic information.

(B)Nothing in subparagraph (A) or in paragraphs (1) and (2) of subsection (d) shall be construed to limit the ability of a group health plan to increase the premium for an employer based on the manifestation of a disease or disorder of an individual who is enrolled in the plan. In such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the employer.

(c)(1)A group health plan may not request or require an individual or a family member of such individual to undergo a genetic test.

(2)Paragraph (1) shall not be construed to limit the authority of a health care professional who is providing health care services to an individual to request that such individual undergo a genetic test.

(3)(A)Nothing in paragraph (1) shall be construed to preclude a group health plan from obtaining and using the results of a genetic test in making a determination regarding payment (as such term is defined for the purposes of applying the regulations promulgated by the Secretary of Health and Human Services under part C of title XI of the Social Security Act and section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time) consistent with subsection (a).

(B)For purposes of subparagraph (A), a group health plan may request only the minimum amount of information necessary to accomplish the intended purpose.

(4)Notwithstanding paragraph (1), a group health plan may request, but not require, that a participant or beneficiary undergo a genetic test if each of the following conditions is met:

(A)The request is made pursuant to research that complies with part 46 of title 45, Code of Federal Regulations, or equivalent Federal regulations, and any applicable State or local law or regulations for the protection of human subjects in research.

(B)The plan clearly indicates to each participant or beneficiary, or in the case of a minor child, to the legal guardian of such beneficiary, to whom the request is made that—

(i)compliance with the request is voluntary; and

(ii)non-compliance will have no effect on enrollment status or premium or contribution amounts.

(C)No genetic information collected or acquired under this paragraph shall be used for underwriting purposes.

(D)The plan notifies the Secretary in writing that the plan is conducting activities pursuant to the exception provided for under this paragraph, including a description of the activities conducted.

(E)The plan complies with such other conditions as the Secretary may by regulation require for activities conducted under this paragraph.

(d)(1)A group health plan shall not request, require, or purchase genetic information for underwriting purposes (as defined in section 9832).

(2)A group health plan shall not request, require, or purchase genetic information with respect to any individual prior to such individual’s enrollment under the plan or in connection with such enrollment.

(3)If a group health plan obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of paragraph (2) if such request, requirement, or purchase is not in violation of paragraph (1).

(e)The provisions of subsections (a)(1)(F), (b)(3), (c), and (d) and subsection (b)(1) and section 9801 with respect to genetic information, shall apply to group health plans without regard to section 9831(a)(2).

(f)A church plan (as defined in section 414(e)) shall not be treated as failing to meet the requirements of this section solely because such plan requires evidence of good health for coverage of—

(1)both any employee of an employer with 10 or less employees (determined without regard to section 414(e)(3)(C)) and any self-employed individual, or

(2)any individual who enrolls after the first 90 days of initial eligibility under the plan.

(g)Any reference in this chapter to genetic information concerning an individual or family member of an individual shall—

(1)with respect to such an individual or family member of an individual who is a pregnant woman, include genetic information of any fetus carried by such pregnant woman; and

(2)with respect to an individual or family member utilizing an assisted reproductive technology, include genetic information of any embryo legally held by the individual or family member.

Notes & Related Subsidiaries

Editorial Notes

References in Text

The Social Security Act, referred to in subsec. (c)(3)(A), 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 Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. section 264 of the Health Insurance Portability and Accountability Act of 1996, referred to in subsec. (c)(3)(A), is section 264 of Pub. L. 104–191, which is set out as a note under section 1320d–2 of Title 42, The Public Health and Welfare.

Amendments

2014—Subsecs. (f), (g). Pub. L. 113–295 redesignated subsec. (f) relating to genetic information of a fetus or embryo as (g). 2008—Subsec. (b)(2)(A). Pub. L. 110–233, § 103(a)(1), inserted “except as provided in paragraph (3)” before semicolon. Subsec. (b)(3). Pub. L. 110–233, § 103(a)(2), added par. (3). Subsecs. (c) to (e). Pub. L. 110–233, § 103(b), added subsecs. (c) to (e). Former subsec. (c) redesignated (f) relating to special rules for church plans. Subsec. (f). Pub. L. 110–233, § 103(c), added subsec. (f) relating to genetic information of a fetus or embryo. Pub. L. 110–233, § 103(b), redesignated subsec. (c) as (f) relating to special rules for church plans. 1997—Subsec. (c). Pub. L. 105–34 added subsec. (c).

Statutory Notes and Related Subsidiaries

Effective Date

of 2008 Amendment Pub. L. 110–233, title I, § 103(f)(2), May 21, 2008, 122 Stat. 899, provided that: “The

Amendments

made by this section [enacting section 9834 of this title and amending this section and section 9832 of this title] shall apply with respect to group health plans for plan years beginning after the date that is 1 year after the date of the enactment of this Act [May 21, 2008].”

Effective Date

of 1997 Amendment Pub. L. 105–34, title XV, § 1532(b), Aug. 5, 1997, 111 Stat. 1085, provided that: “The

Amendments

made by subsection (a) [amending this section] shall take effect as if included in the

Amendments

made by section 401(a) of the Health Insurance Portability and Accountability Act of 1996 [Pub. L. 104–191].”

Regulations

Pub. L. 110–233, title I, § 103(f)(1), May 21, 2008, 122 Stat. 899, provided that: “The Secretary of the Treasury shall issue final

Regulations

or other guidance not later than 12 months after the date of the enactment of this Act [May 21, 2008] to carry out the

Amendments

made by this section [enacting section 9834 of this title and amending this section and section 9832 of this title].”

Effective Date

Section applicable to plan years beginning after June 30, 1997, see section 401(c) of Pub. L. 104–191, set out as a note under section 9801 of this title.

§9802 Prohibiting Discrimination Against Individual Participants and Beneficiaries Based on Health Status

Summary

Title 26, §9802

Notes & Related Subsidiaries

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Regulations

Regulations

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