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 2701(c)(1) (!1) is
      provided shall be treated as a group health plan for purposes of
      applying section 2701(e).(!1)

    (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 2702(a)(1).(!1)
      (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.
      (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 (!2) 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 101 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
      100 employees on business days during the preceding calendar year
      and who employs at least 1 employees (!3) 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 (!4) 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.