Collapse to view only § 9832. Definitions
§ 9831. General exceptions
(a) Exception for certain plans
The requirements of this chapter shall not apply to—
(1) any governmental plan, and
(2) any group health plan for any plan year if, on the first day of such plan year, such plan has less than 2 participants who are current employees.
(b) Exception for certain benefits
(c) Exception for certain benefits if certain conditions met
(1) Limited, excepted benefits
The requirements of this chapter shall not apply to any group health plan in relation to its provision of excepted benefits described in section 9832(c)(2) if the benefits—
(A) are provided under a separate policy, certificate, or contract of insurance; or
(B) are otherwise not an integral part of the plan.
(2) Noncoordinated, excepted benefits
The requirements of this chapter shall not apply to any group health plan in relation to its provision of excepted benefits described in section 9832(c)(3) if all of the following conditions are met:
(A) The benefits are provided under a separate policy, certificate, or contract of insurance.
(B) There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.
(C) Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.
(3) Supplemental excepted benefits
(d) Exception for qualified small employer health reimbursement arrangements
(1) In general
(2) Qualified small employer health reimbursement arrangement
For purposes of this subsection—
(A) In general
The term “qualified small employer health reimbursement arrangement” means an arrangement which—
(i) is described in subparagraph (B), and
(ii) is provided on the same terms to all eligible employees of the eligible employer.
(B) Arrangement described
An arrangement is described in this subparagraph if—
(i) such arrangement is funded solely by an eligible employer and no salary reduction contributions may be made under such arrangement,
(ii) such arrangement provides, after the employee provides proof of coverage, for the payment of, or reimbursement of, an eligible employee for expenses for medical care (as defined in section 213(d)) incurred by the eligible employee or the eligible employee’s family members (as determined under the terms of the arrangement), and
(iii) the amount of payments and reimbursements described in clause (ii) for any year do not exceed $4,950 ($10,000 in the case of an arrangement that also provides for payments or reimbursements for family members of the employee).
(C) Certain variation permitted
For purposes of subparagraph (A)(ii), an arrangement shall not fail to be treated as provided on the same terms to each eligible employee merely because the employee’s permitted benefit under such arrangement varies in accordance with the variation in the price of an insurance policy in the relevant individual health insurance market based on—
(i) the age of the eligible employee (and, in the case of an arrangement which covers medical expenses of the eligible employee’s family members, the age of such family members), or
(ii) the number of family members of the eligible employee the medical expenses of which are covered under such arrangement.
The variation permitted under the preceding sentence shall be determined by reference to the same insurance policy with respect to all eligible employees.
(D) Rules relating to maximum dollar limitation
(i) Amount prorated in certain cases
(ii) Inflation adjustment
In the case of any year beginning after 2016, each of the dollar amounts in subparagraph (B)(iii) shall be increased by an amount equal to—
(I) such dollar amount, multiplied by(II) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins, determined by substituting “calendar year 2015” for “calendar year 2016” in subparagraph (A)(ii) thereof. If any dollar amount increased under the preceding sentence is not a multiple of $50, such dollar amount shall be rounded to the next lowest multiple of $50.
(3) Other definitions
For purposes of this subsection—
(A) Eligible employee
(B) Eligible employer
The term “eligible employer” means an employer that—
(i) is not an applicable large employer as defined in section 4980H(c)(2), and
(ii) does not offer a group health plan to any of its employees.
(C) Permitted benefit
(4) Notice
(A) In general
(B) Contents of notice
The notice required under subparagraph (A) shall include each of the following:
(i) A statement of the amount which would be such eligible employee’s permitted benefit under the arrangement for the year.
(ii) A statement that the eligible employee should provide the information described in clause (i) to any health insurance exchange to which the employee applies for advance payment of the premium assistance tax credit.
(iii) A statement that if the employee is not covered under minimum essential coverage for any month the employee may be subject to tax under section 5000A for such month and reimbursements under the arrangement may be includible in gross income.
(Added Pub. L. 104–191, title IV, § 401(a), Aug. 21, 1996, 110 Stat. 2080, § 9804; renumbered § 9831 and amended Pub. L. 105–34, title XV, § 1531(a)(2), (b)(1)(B)–(E), Aug. 5, 1997, 111 Stat. 1081, 1084, 1085; Pub. L. 114–255, div. C, title XVIII, § 18001(a)(1), Dec. 13, 2016, 130 Stat. 1338; Pub. L. 115–97, title I, § 11002(d)(1)(TT), Dec. 22, 2017, 131 Stat. 2061; Pub. L. 116–94, div. N, title I, § 503(b)(2), Dec. 20, 2019, 133 Stat. 3119.)
§ 9832. Definitions
(a) Group health plan
(b) Definitions relating to health insurance
For purposes of this chapter—
(1) Health insurance coverage
(A) In general
(B) No application to certain excepted benefits
(2) Health insurance issuer
(3) Health maintenance organization
The term “health maintenance organization” means—
(A) a federally qualified health maintenance organization (as defined in section 1301(a) of the Public Health Service Act (42 U.S.C. 300e(a))),
(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.
(c) Excepted benefits
For purposes of this chapter, 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
(d) Other definitions
For purposes of this chapter—
(1) COBRA continuation provision
The term “COBRA continuation provision” means any of the following:
(A) Section 4980B, other than subsection (f)(1) thereof 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.
(C) Title XXII of the Public Health Service Act.
(2) Governmental plan
(3) Medical care
The term “medical care” has the meaning given such term by section 213(d) determined without regard to—
(A) paragraph (1)(C) thereof, and
(B) so much of paragraph (1)(D) thereof as relates to qualified long-term care insurance.
(4) Network plan
(5) Placed for adoption defined
(6) Family member
The term “family member” means, with respect to any individual—
(A) a dependent (as such term is used for purposes of section 9801(f)(2)) 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).
(7) 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
(C) Exclusions
(8) Genetic test
(A) In general
(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.
(9) 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.
(10) 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.
(Added Pub. L. 104–191, title IV, § 401(a), Aug. 21, 1996, 110 Stat. 2080, § 9805; renumbered § 9832, Pub. L. 105–34, title XV, § 1531(a)(2), Aug. 5, 1997, 111 Stat. 1081; amended Pub. L. 110–233, title I, § 103(d), May 21, 2008, 122 Stat. 898.)
§ 9833. Regulations
The Secretary, consistent with section 104 of the Health Care Portability and Accountability Act of 1996, may promulgate such regulations as may be necessary or appropriate to carry out the provisions of this chapter. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this chapter.
(Added Pub. L. 104–191, title IV, § 401(a), Aug. 21, 1996, 110 Stat. 2082; § 9806; renumbered § 9833, Pub. L. 105–34, title XV, § 1531(a)(2), Aug. 5, 1997, 111 Stat. 1081.)
§ 9834. Enforcement
For the imposition of tax on any failure of a group health plan to meet the requirements of this chapter, see section 4980D.
(Added Pub. L. 110–233, title I, § 103(e)(1), May 21, 2008, 122 Stat. 899.)