29 USC 1191 - Special rules relating to group health plans

Collapse to view only § 1191a. Special rules relating to group health plans

§ 1191. Preemption; State flexibility; construction
§ 1191a. Special rules relating to group health plans
§ 1191b. Definitions
§ 1191c. Regulations
§ 1191d. Standardized reporting format

§ 1191. Preemption; State flexibility; construction

(a) Continued applicability of State law with respect to health insurance issuers

(1) In general

(2) Continued preemption with respect to group health plans

(b) Special rules in case of portability requirements

(1) In general

(2) Exceptions

Only in relation to health insurance coverage offered by a health insurance issuer, the provisions of this part do not supersede any provision of State law to the extent that such provision—

(A) substitutes for the reference to “6-month period” in section 1181(a)(1) of this title a reference to any shorter period of time;

(B) substitutes for the reference to “12 months” and “18 months” in section 1181(a)(2) of this title a reference to any shorter period of time;

1 So in original. Section 1181(d)(4) of this title does not contain subpars.

of this title a reference to any greater number of days;

(D) substitutes for the reference to “30-day period” in sections 1181(b)(2) 2

2 So in original. Section 1181(b)(2) of this title does not refer to a 30-day period.

and (d)(1) of this title a reference to any greater period;

(E) prohibits the imposition of any preexisting condition exclusion in cases not described in section 1181(d) of this title or expands the exceptions described in such section;

(F) requires special enrollment periods in addition to those required under section 1181(f) of this title; or

(G) reduces the maximum period permitted in an affiliation period under section 1181(g)(1)(B) 3

3 So in original. Probably should be “1181(g)(1)(C)”.

of this title.

(d) Definitions

For purposes of this section—

(1) State law

(2) State

(Pub. L. 93–406, title I, § 731, formerly § 704, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1946; renumbered § 731 and amended Pub. L. 104–204, title VI, § 603(a)(3), (b)(1), Sept. 26, 1996, 110 Stat. 2935, 2937.)

§ 1191a. Special rules relating to group health plans

(a) General exception for certain small group health plans

(b) Exception for certain benefits

(1) Limited, excepted benefits

The requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) in relation to its provision of excepted benefits described in section 1191b(c)(2) of this title 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

(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) Treatment of partnerships

For purposes of this part—

(1) Treatment as a group health plan

(2) Employer

(3) Participants of group health plans

In the case of a group health plan, the term “participant” also includes—

(A) in connection with a group health plan maintained by a partnership, an individual who is a partner in relation to the partnership, or

(B) in connection with a group health plan maintained by a self-employed individual (under which one or more employees are participants), the self-employed individual,

if such individual is, or may become, eligible to receive a benefit under the plan or such individual’s beneficiaries may be eligible to receive any such benefit.

(Pub. L. 93–406, title I, § 732, formerly § 705, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1948; renumbered § 732 and amended Pub. L. 104–204, title VI, § 603(a)(3), (b)(2), (3)(I)–(L), Sept. 26, 1996, 110 Stat. 2935, 2937, 2938.)

§ 1191b. Definitions

(a) Group health plan

For purposes of this part—

(1) In general

(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

(b) Definitions relating to health insurance

For purposes of this part—

(1) Health insurance coverage

(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.

(4) Group health insurance coverage

For purposes of this part, 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.

(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.

(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 part—

(1) COBRA continuation provision

The term “COBRA continuation provision” means any of the following:

(A) Part 6 of this subtitle.

(B)Section 4980B of title 26, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.

(2) Health status-related factor

(3) Network plan

(4) Placed for adoption

(5) Family member

The term “family member” means, with respect to an individual—

(A) a dependent (as such term is used for purposes of section 1181(f)(2) of this title) 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).

(6) 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

(7) 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.

(8) Genetic services

The term “genetic services” means—

(A) a genetic test;

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

(9) 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;

(D) other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.

(Pub. L. 93–406, title I, § 733, formerly § 706, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1949; renumbered § 733, Pub. L. 104–204, title VI, § 603(a)(3), Sept. 26, 1996, 110 Stat. 2935; amended Pub. L. 110–233, title I, § 101(d), May 21, 2008, 122 Stat. 885; Pub. L. 114–255, div. C, title XVIII, § 18001(b)(1), Dec. 13, 2016, 130 Stat. 1343.)

§ 1191c. 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 part. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this part.

(Pub. L. 93–406, title I, § 734, formerly § 707, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1951; renumbered § 734, Pub. L. 104–204, title VI, § 603(a)(3), Sept. 26, 1996, 110 Stat. 2935.)

§ 1191d. Standardized reporting format

(a) In general

(b) Consultation

(1) Advisory Committee

(2) Membership

(A) Appointment

(B) CompositionThe Committee shall be comprised of—

(i) the Assistant Secretary of Employee Benefits and Security Administration of the Department of Labor, or a designee of such Assistant Secretary;

(ii) the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services, or a designee of such Assistant Secretary;

(iii) members appointed by the Secretary, in coordination with the Secretary of Health and Human Services, including—(I) 1 member to serve as the chair of the Committee;(II) 1 representative of the Centers for Medicare & Medicaid Services;(III) 1 representative of the Agency for Healthcare Research and Quality;(IV) 1 representative of the Office for Civil Rights of the Department of Health and Human Services with expertise in data privacy and security;(V) 1 representative of the National Center for Health Statistics;(VI) 1 representative of the Office of the National Coordinator for Health Information Technology; and(VII) 1 representative of a State All-Payer 2

2 So in original. Definition in subsec. (c) does not contain hyphen in “All Payer”.

Claims Database;

(iv) members appointed by the Comptroller General of the United States, including—(I) 1 representative of an employer that sponsors a group health plan;(II) 1 representative of an employee organization that sponsors a group health plan;(III) 1 academic researcher with expertise in health economics or health services research;(IV) 1 consumer advocate; and(V) 2 additional members.

(3) Report

(d) Authorization of appropriations

(e) Sunset

(Pub. L. 93–406, title I, § 735, as added Pub. L. 116–260, div. BB, title I, § 115(b), Dec. 27, 2020, 134 Stat. 2877.)