42 U.S.C. § 18024: Related definitions

Summary

Defines key words used for health insurance rules. A "group market" is where people get coverage through an employer plan for themselves and dependents. The "individual market" is coverage sold to people not through an employer plan. "Large group market" and "small group market" are group markets for plans run by large or small employers. Says what counts as a large or small employer. A large employer employed an average of at least 51 employees on business days in the prior calendar year and has at least 1 employee on the first day of the plan year. A small employer employed an average of at least 1 but not more than 50 employees in the prior year and has at least 1 employee on the first day of the plan year. A State may treat employers with 1 to 100 employees as small. Employers treated as one under section 414 of the tax code are counted as a single employer. New employers are judged by the number they are expected to employ this year. References to an employer include its predecessor. If a small employer offered Exchange enrollment to employees and then grows bigger, it stays treated as small until it stops offering that enrollment. "Secretary" means the Secretary of Health and Human Services. "State" means the 50 States and the District of Columbia. An "educated health care consumer" is a person who knows about the health system and can make informed health and medical choices.

Title 42, §18024

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

(a)Definitions relating to markets

In this title:

(1)Group market

The term “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 an employer.

(2)Individual market

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

(3)Large and small group markets

The terms “large group market” and “small group market” mean 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 (as defined in subsection (b)(1)) or by a small employer (as defined in subsection (b)(2)), respectively.

(b)Employers

In this title: 1

(1)Large employer

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 1 employee on the first day of the plan year.

(2)Small employer

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 employee on the first day of the plan year.

(3)State option to extend definition of small employer

Notwithstanding paragraphs (1) and (2), 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.

(4)Rules for determining employer size

For purposes of this subsection

(A) Application of aggregation rule for employers

(B)Employers not in existence in preceding year

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)Predecessors

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

(D)Continuation of participation for growing small employers

If—

(i)a qualified employer that is a small employer makes enrollment in qualified health plans offered in the small group market available to its employees through an Exchange; and

(ii)the employer ceases to be a small employer by reason of an increase in the number of employees of such employer;

the employer shall continue to be treated as a small employer for purposes of this subchapter for the period beginning with the increase and ending with the first day on which the employer does not make such enrollment available to its employees.

(c)Secretary

In this title,1 the term “Secretary” means the Secretary of Health and Human Services.

(d)State

In this title,1 the term “State” means each of the 50 States and the District of Columbia.

(e)Educated health care consumers

The term “educated health care consumer” means an individual who is knowledgeable about the health care system, and has background or experience in making informed decisions regarding health, medical, and scientific matters.

Notes & Related Subsidiaries

Editorial Notes

References in Text

This title, referred to in subsecs. (a) to (d), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables.

Amendments

2015—Subsec. (b)(1). Pub. L. 114–60, § 2(a)(1), substituted “51” for “101”. Subsec. (b)(2). Pub. L. 114–60, § 2(a)(2), substituted “50” for “100”. Subsec. (b)(3). Pub. L. 114–60, § 2(a)(3), amended par. (3) generally. Prior to amendment, text read as follows: “In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by substituting ‘51 employees’ for ‘101 employees’ in paragraph (1) and by substituting ‘50 employees’ for ‘100 employees’ in paragraph (2).” 2010—Subsec. (e). Pub. L. 111–148, § 10104(d), added subsec. (e).

§18024 Related Definitions