42 U.S.C. § 300gg-91 : US Code - Section 300GG-91: Definitions

Search 42 U.S.C. § 300gg-91 : US Code - Section 300GG-91: Definitions

(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.
(2) Medical care
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) 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 300gg(c)(1) of this
title is provided shall be treated as a group health plan for
purposes of applying section 300gg(e) of this title.
(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
The term "health status-related factor" means any of the
factors described in section 300gg-1(a)(1) of this title.
(10) Network plan
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) 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
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) State
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.
(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 (!1) 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 2 but not more than
50 employees on business days during the preceding calendar year
and who employs at least 2 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
all (!2) 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) 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.