View all text of Part C [§ 300gg-91 - § 300gg-95]
§ 300gg–91. Definitions
(a) Group health plan
(1) Definition
(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
(b) Definitions relating to health insurance
(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 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
(5) Individual health insurance coverage
(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
(d) Other definitions
(1) Applicable State authority
(2) Beneficiary
(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
(6) Employer
(7) Church plan
(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
(11) Participant
(12) Placed for adoption defined
(13) Plan sponsor
(14) State
(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
(C) Exclusions
(17) 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.
(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
(21) Exchange
(e) Definitions relating to markets and small employers
For purposes of this subchapter:
(1) Individual market
(A) In general
(B) Treatment of very small groups
(i) In general
(ii) State exception
(2) Large employer
(3) Large group market
(4) Small employer
(5) Small group market
(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
(C) Predecessors
(7) State option to extend definition of small employer
(July 1, 1944, ch. 373, title XXVII, § 2791, as added Pub. L. 104–191, title I, § 102(a), Aug. 21, 1996, 110 Stat. 1972; amended Pub. L. 110–233, title I, § 102(a)(4), May 21, 2008, 122 Stat. 890; Pub. L. 111–148, title I, § 1563(b), (c)(16), formerly § 1562(b), (c)(16), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 264, 269, 911; Pub. L. 114–60, § 2(b), Oct. 7, 2015, 129 Stat. 543; Pub. L. 114–255, div. C, title XVIII, § 18001(c)(1), Dec. 13, 2016, 130 Stat. 1344.)