42 U.S.C. § 300gg–91: Definitions

Summary

Defines many key words used for federal rules about health plans and health insurance. A "group health plan" is an employee benefit plan that pays for medical care for employees or their dependents, directly or by buying insurance. "Medical care" means paying for diagnosis, treatment, prevention, care that affects the body, transportation essential to care, and insurance for those things. "Health insurance coverage" means benefits for medical care offered under a policy, plan, or HMO. A "health insurance issuer" is an insurance company or similar organization licensed and regulated by a State. Some plans are treated as group plans for certain notice rules. "Excepted benefits" are limited kinds of coverage that are not treated like regular health plans, such as accident or disability-only coverage, liability supplements, workers’ compensation, on-site clinic care, limited dental or vision, long-term care, specified-disease or hospital indemnity plans, and Medicare or military supplemental policies. Also defines many other terms in one line each. "Applicable State authority" is the State insurance official. "Bona fide association" must exist at least 5 years, have real purposes besides getting insurance, and must offer coverage to all members without using health-status rules. "COBRA continuation provision" refers to certain federal laws listed by section (including section 4980B of title 26 with one exception, parts of ERISA, and Subchapter XX). "Employee," "employer," "participant," "beneficiary," "plan sponsor," and "church" or "governmental plan" point to other federal definitions, with "employer" limited to those with two or more employees. A "network plan" uses a set of contracted providers. "Genetic information" covers a person’s genetic tests, family tests, and family disease history, plus requests for genetic services or participation in genetic research, but not sex or age. A "genetic test" looks for genotypes, mutations, or chromosomal changes in DNA, RNA, chromosomes, proteins, or metabolites, with stated exceptions. "Underwriting purposes" covers rules about eligibility, premiums, pre‑existing conditions, and other activities tied to creating or renewing coverage. The rules also define the individual, small, and large employer markets—small employers are those with at least 1 but not more than 50 employees (States may treat 1–100 as small), and a large employer is one with an average of at least 51 employees.

Title 42, §300gg–91

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

(a)Group health plan

(1)Definition

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)Medical care

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

(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)Treatment of certain plans as group health plan for notice provision

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

(b)Definitions relating to health insurance

(1)Health insurance coverage

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)Health insurance issuer

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)Health maintenance organization

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)Group health insurance coverage

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

(5)Individual health insurance coverage

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)Excepted benefits

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

(1)Benefits not subject to requirements

(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)Benefits not subject to requirements if offered separately

(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)Benefits not subject to requirements if offered as independent, noncoordinated benefits

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

(B)Hospital indemnity or other fixed indemnity insurance.

(4)Benefits not subject to requirements if offered as separate insurance policy

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)Other definitions

(1)Applicable State authority

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)Beneficiary

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)Bona fide association

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)COBRA continuation provision

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)Employee

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)Employer

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)Church plan

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)Governmental plan

(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)Federal governmental plan.—

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)Non-Federal governmental plan.—

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

(9)Health status-related factor (10) Network plan

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

(11)Participant

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)Placed for adoption defined

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)Plan sponsor (14) State

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)].

(15)Family member

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)Genetic information

(A)In general

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)Inclusion of genetic services and participation in genetic research

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)Exclusions

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

(17)Genetic test

(A)In general

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

(B)Exceptions

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)Genetic services

The term “genetic services” means—

(A)a genetic test;

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

(C)genetic education.

(19)Underwriting purposes

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)Qualified health plan

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

(21)Exchange

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

(e)Definitions relating to markets and small employers

For purposes of this subchapter:

(1)Individual market

(A)In general

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

(B)Treatment of very small groups

(i)In general

Subject to clause (ii), such terms 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)State exception

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)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 2 employees on the first day of the plan year.

(3)Large group market

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)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 employees on the first day of the plan year.

(5)Small group market

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)Application of certain rules in determination of 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.

(7)State option to extend definition of small employer

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