§1191b Definitions

Summary

Gives clear meanings for many words about health plans so people know what the rules talk about. Group health plan — an employer’s benefit plan that pays for medical care for workers or their dependents, directly or through insurance; it does not include qualified small employer health reimbursement arrangements. Medical care — money paid for finding, treating, preventing, or affecting body functions, travel needed for that care, and insurance that pays for those things. Health insurance coverage — benefits that pay for medical care under a policy, plan, or HMO contract sold by an insurer. Health insurance issuer — an insurance company or similar organization licensed and regulated by a State; not a group health plan. Health maintenance organization — a federally qualified HMO, one recognized by State law, or a similar State-regulated organization. Group health insurance coverage — health insurance offered with a group health plan. Excepted benefits — certain limited kinds of coverage that are not treated like regular group health benefits, such as accident-only or disability plans, liability and workers’ compensation, on-site clinic coverage, limited dental or vision, long-term care, specified-disease or hospital fixed indemnity plans, Medicare or other supplemental coverage, and similar limited items. COBRA continuation provision — the federal laws that require continuation of coverage, including specified parts of the Public Health Service Act and other federal rules. Health status-related factor — the factors listed in section 1182(a)(1). Network plan — coverage that gets care through a defined set of contracted providers. Placement for adoption — has the meaning given in section 1169(c)(3)(B). Family member — a dependent plus any relative within the first through fourth degree of the person or that dependent. Genetic information — information about a person’s or family member’s genetic tests, family disease history, requests for or receipt of genetic services, or participation in genetic research; does not include sex or age. Genetic test — an analysis of DNA, RNA, chromosomes, proteins, or metabolites that finds genotypes, mutations, or chromosomal changes, but not certain protein or metabolite tests that don’t detect genetic changes or that only relate to an already evident condition. Genetic services — genetic tests, genetic counseling, or genetic education. Underwriting purposes — activities like deciding eligibility, setting premiums, applying pre-existing condition rules, and other actions tied to creating, renewing, or replacing health coverage.