Part C—Definitions; Miscellaneous Provisions
§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 [
(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 [
(3) Health maintenance organization
The term "health maintenance organization" means—
(A) a Federally qualified health maintenance organization (as defined in
(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
(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 [
(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)
(B) Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 [
(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 [
(6) Employer
The term "employer" has the meaning given such term under section 3(5) of the Employee Retirement Income Security Act of 1974 [
(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 [
(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 [
(B)
(C)
(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 [
(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 [
(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
(21) Exchange
The term "Exchange" means an American Health Benefit Exchange established under
(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 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 1 but not more than 50 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
(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.
(7) State option to extend definition of small employer
Notwithstanding paragraphs (2) and (4), nothing in this section shall prevent a State from applying this subsection by treating as a small employer, 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 employee on the first day of the plan year.
(July 1, 1944, ch. 373, title XXVII, §2791, as added
Editorial Notes
References in Text
The Social Security Act, referred to in subsec. (a)(1), is act Aug. 14, 1935, ch. 531,
Section 2701, referred to in subsecs. (a)(3) and (d)(15)(A), is a reference to section 2701 of act July 1, 1944. Section 2701, which was classified to
The Employee Retirement Income Security Act of 1974, referred to in subsec. (d)(4)(B), is
Section 2702, referred to in subsec. (d)(9), is a reference to section 2702 of act July 1, 1944. Section 2702, which was classified to
Amendments
2016—Subsec. (a)(1).
2015—Subsec. (e)(2).
Subsec. (e)(4).
Subsec. (e)(7).
2010—Subsec. (d)(20), (21).
Subsec. (e)(2).
Subsec. (e)(4).
2008—Subsec. (d)(15) to (19).
Statutory Notes and Related Subsidiaries
Effective Date of 2016 Amendment
Amendment by
Effective Date of 2008 Amendment
Amendment by
1 See References in Text note below.
2 So in original. Probably should be "term".
4 So in original. Probably should be capitalized.
§300gg–92. 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 subchapter. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this subchapter.
(July 1, 1944, ch. 373, title XXVII, §2792, as added
Editorial Notes
References in Text
Section 104 of the Health Care Portability and Accountability Act of 1996, referred to in text, probably means section 104 of the Health Insurance Portability and Accountability Act of 1996,
Statutory Notes and Related Subsidiaries
Assuring Coordination Among Departments of Treasury, Health and Human Services, and Labor
"(1) regulations, rulings, and interpretations issued by such Secretaries relating to the same matter over which two or more such Secretaries have responsibility under this subtitle [subtitle A (§§101–104) of title I of
"(2) coordination of policies relating to enforcing the same requirements through such Secretaries in order to have a coordinated enforcement strategy that avoids duplication of enforcement efforts and assigns priorities in enforcement."
§300gg–93. Health insurance consumer information
(a) In general
The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for—
(1) offices of health insurance consumer assistance; or
(2) health insurance ombudsman programs.
(b) Eligibility
(1) In general
To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.
(2) Criteria
A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.
(c) Duties
The office of health insurance consumer assistance or health insurance ombudsman shall—
(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;
(2) collect, track, and quantify problems and inquiries encountered by consumers;
(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;
(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and
(5) resolve problems with obtaining premium tax credits under
(d) Data collection
As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
(e) Funding
(1) Initial funding
There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain available without fiscal year limitation.
(2) Authorization for subsequent years
There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.
(July 1, 1944, ch. 373, title XXVII, §2793, as added
Statutory Notes and Related Subsidiaries
Effective Date
Section effective for fiscal years beginning with fiscal year 2010, see section 1004(a) of
Section effective Mar. 23, 2010, see section 1004(b) of
§300gg–94. Ensuring that consumers get value for their dollars
(a) Initial premium review process
(1) In general
The Secretary, in conjunction with States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage.
(2) Justification and disclosure
The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers.
(b) Continuing premium review process
(1) Informing Secretary of premium increase patterns
As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall—
(A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and
(B) make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases.
(2) Monitoring by Secretary of premium increases
(A) In general
Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange.
(B) Consideration in opening Exchange
In determining under
(c) Grants in support of process
(1) Premium review grants during 2010 through 2014
The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including—
(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage;
(B) in providing information and recommendations to the Secretary under subsection (b)(1); and
(C) in establishing centers (consistent with subsection (d)) at academic or other nonprofit institutions to collect medical reimbursement information from health insurance issuers, to analyze and organize such information, and to make such information available to such issuers, health care providers, health researchers, health care policy makers, and the general public.
(2) Funding
(A) In general
Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B).
(B) Further availability for insurance reform and consumer protection
If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A.
(C) Allocation
The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula—
(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and
(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.
(3) Parity implementation
(A) In general
Beginning during the first fiscal year that begins after December 29, 2022, the Secretary shall, out of funds made available pursuant to subparagraph (C), award grants to eligible States to enforce and ensure compliance with the mental health and substance use disorder parity provisions of section 300gg––26 of this title.
(B) Eligible State
A State shall be eligible for a grant awarded under this paragraph only if such State—
(i) submits to the Secretary an application for such grant at such time, in such manner, and containing such information as specified by the Secretary; and
(ii) agrees to request and review from health insurance issuers offering group or individual health insurance coverage the comparative analyses and other information required of such health insurance issuers under subsection (a)(8)(A) of
(C) Authorization of appropriations
There are authorized to be appropriated $10,000,000 for each of the first five fiscal years beginning after December 29, 2022, to remain available until expended, for purposes of awarding grants under subparagraph (A).
(d) Medical reimbursement data centers
(1) Functions
A center established under subsection (c)(1)(C) shall—
(A) develop fee schedules and other database tools that fairly and accurately reflect market rates for medical services and the geographic differences in those rates;
(B) use the best available statistical methods and data processing technology to develop such fee schedules and other database tools;
(C) regularly update such fee schedules and other database tools to reflect changes in charges for medical services;
(D) make health care cost information readily available to the public through an Internet website that allows consumers to understand the amounts that health care providers in their area charge for particular medical services; and
(E) regularly publish information concerning the statistical methodologies used by the center to analyze health charge data and make such data available to researchers and policy makers.
(2) Conflicts of interest
A center established under subsection (c)(1)(C) shall adopt by-laws that ensures that the center (and all members of the governing board of the center) is independent and free from all conflicts of interest. Such by-laws shall ensure that the center is not controlled or influenced by, and does not have any corporate relation to, any individual or entity that may make or receive payments for health care services based on the center's analysis of health care costs.
(3) Rule of construction
Nothing in this subsection shall be construed to permit a center established under subsection (c)(1)(C) to compel health insurance issuers to provide data to the center.
(July 1, 1944, ch. 373, title XXVII, §2794, as added and amended
Editorial Notes
Prior Provisions
A prior section 2794 of act July 1, 1944, was renumbered section 2795 and is classified to
Amendments
2022—Subsec. (c)(3).
2010—Subsec. (c)(1)(C).
Subsec. (d).
Statutory Notes and Related Subsidiaries
Effective Date
Section effective for fiscal years beginning with fiscal year 2010, see section 1004(a) of
Section effective Mar. 23, 2010, see section 1004(b) of
§300gg–95. Uniform fraud and abuse referral format
The Secretary shall request the National Association of Insurance Commissioners to develop a model uniform report form for private health insurance issuer 1 seeking to refer suspected fraud and abuse to State insurance departments or other responsible State agencies for investigation. The Secretary shall request that the National Association of Insurance Commissioners develop recommendations for uniform reporting standards for such referrals.
(July 1, 1944, ch. 373, title XXVII, §2795, formerly §2794, as added