
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC300gg-91]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                    CHAPTER 6A--PUBLIC HEALTH SERVICE
 
   SUBCHAPTER XXV--REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
 
              Part C--Definitions; Miscellaneous Provisions
 
Sec. 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.
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    \1\ So in original. Probably should be ``term''.
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            (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.
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    \2\ So in original. Probably should be capitalized.
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        (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.

(July 1, 1944, ch. 373, title XXVII, Sec. 2791, as added Pub. L. 104-
191, title I, Sec. 102(a), Aug. 21, 1996, 110 Stat. 1972.)

                       References in Text

    The Employee Retirement Income Security Act of 1974, referred to in 
subsec. (d)(4)(B), is Pub. L. 93-406, Sept. 2, 1974, 88 Stat. 829, as 
amended. Part 6 of subtitle B of title I of the Act is classified 
generally to part 6 (Sec. 1161 et seq.) of subtitle B of subchapter I of 
chapter 18 of Title 29, Labor. For complete classification of this Act 
to the Code, see Short Title note set out under section 1001 of Title 29 
and Tables.

                  Section Referred to in Other Sections

    This section is referred to in sections 300e, 300gg, 300gg-11, 
300gg-21, 300gg-41, 300gg-63, 1320d, 1397cc, 1397ii, 1397jj of this 
title; title 21 section 360aaa-5.
