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26 U.S.C. § 9832 — Definitions
Federal law — U.S. Code and appendices · legal_authorities
**(a) Group health plan** For purposes of this chapter, the term “group health plan” has the meaning given to such term by section 5000(b)(1).
**(b) Definitions relating to health insurance** For purposes of this chapter—
(1) **Health insurance coverage**
(A) *In general* — Except as provided in subparagraph (B), the term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) 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.
(B) *No application to certain excepted benefits* — In applying subparagraph (A), excepted benefits described in subsection (c)(1) shall not be treated as benefits consisting of medical care.
(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, as in effect on the date of the enactment of this section). 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 1301(a) of the Public Health Service Act ([42 U.S.C. 300e(a)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e/a&num=0&edition=prelim))),
(B) an organization recognized under State law as
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Source location: Title 26, Chapter 100, § 9832; chapter-100-group-health-plan-requirements.md
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**(a) Group health plan** For purposes of this chapter, the term “group health plan” has the meaning given to such term by section 5000(b)(1).
**(b) Definitions relating to health insurance** For purposes of this chapter—
(1) **Health insurance coverage**
(A) *In general* — Except as provided in subparagraph (B), the term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) 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.
(B) *No application to certain excepted benefits* — In applying subparagraph (A), excepted benefits described in subsection (c)(1) shall not be treated as benefits consisting of medical care.
(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, as in effect on the date of the enactment of this section). 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 1301(a) of the Public Health Service Act ([42 U.S.C. 300e(a)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300e/a&num=0&edition=prelim))),
(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** — Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan.
**(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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1161&num=0&edition=prelim) et seq.), other than section 609 of such Act.
(C) Title XXII of the Public Health Service Act.
(2) **Governmental plan** — The term “governmental plan” has the meaning given such term by section 414(d).
(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** — The term “network plan” means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care are provided, in whole or in part, through a defined set of providers under contract with the issuer.
(5) **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.
(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* — 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.
(8) **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.
(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.
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Federal law — U.S. Code and appendices · legal_authorities
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Benefit plans as affecting interstate commerce and the Federal taxing power** The Congress finds that the growth in size, scope, and numbers of employee benefit plans in recent years has been rapid and substantial; that the operational scope and economic impact of such plans is increasingly interstate; that the continued well-being and security of millions of employees and their dependents are directly affected by these plans; that they are affected with a national public interest; that they have become an important factor affecting the stability of employment and the successful development of industrial relations; that they have become an important factor in commerce because of the interstate character of their activities, and of the activities of their participants, and the employers, employee organizations, and other entities by which they are established or maintained; that a large volume of the activities of such plans are carried on by means of the mails and instrumentalities of interstate commerce; that owing to the lack of employee information and adequate safeguards concerning their operation, it is desirable in the interests of employees and their beneficiaries, and to provide for the general welfare and the free flow of commerce, that disclosure be made and safeguards be provided with respect to the establishment, operation, and administration of such plans; that they substantially affect the revenues of the United States because they are afforded preferential Federal tax treatment; that despite the enormous growth in such plans many employees with long years of employment are losing anticipated retirement benefits owing to the lack of vesting provisions in such plans; that owing to the inadequacy of current minimum standards, the soundness and stabilit
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Limitation on preexisting condition exclusion period; crediting for periods of previous coverage** Subject to subsection (d), a group health plan may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if—
(1) such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
(2) such exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and
(3) the period of any such preexisting condition exclusion is reduced by the length of the aggregate of the periods of creditable coverage (if any) applicable to the participant or beneficiary as of the enrollment date.
**(b) Definitions** For purposes of this section—
(1) **Preexisting condition exclusion**
(A) *In general* — The term “preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
(B) *Treatment of genetic information* — For purposes of this section, genetic information shall not be treated as a condition described in subsection (a)(1) in the absence of a diagnosis of the condition related to such information.
(2) **Enrollment date** — The term “enrollment date” means, with respect to an individual covered under a group health plan, the date of enrollment of the individual in the plan or, if earlier, the first day of the waiting per
Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 9801
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Federal law — U.S. Code and appendices · legal_authorities
**(a) In general** The plan sponsor of each group health plan shall provide, in accordance with this part, that each qualified beneficiary who would lose coverage under the plan as a result of a qualifying event is entitled, under the plan, to elect, within the election period, continuation coverage under the plan.
**(b) Exception for certain plans** Subsection (a) shall not apply to any group health plan for any calendar year if all employers maintaining such plan normally employed fewer than 20 employees on a typical business day during the preceding calendar year.
Source: Supplied U.S. Code snapshot — release unconfirmed · 29 U.S.C. § 1161
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Federal law — U.S. Code and appendices · legal_authorities
Beginning with fiscal year 2010, the Secretary shall transfer from the Public Health and Social Services Emergency Fund such sums as may be necessary to carry out this part.
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Federal law — U.S. Code and appendices · legal_authorities
**(a) In eligibility to enroll**
(1) **In general** — Subject to paragraph (2), a group health plan may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following factors in relation to the individual or a dependent of the individual:
(A) Health status.
(B) Medical condition (including both physical and mental illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising out of acts of domestic violence).
(H) Disability.
(2) **No application to benefits or exclusions** — To the extent consistent with section 9801, paragraph (1) shall not be construed—
(A) to require a group health plan to provide particular benefits (or benefits with respect to a specific procedure, treatment, or service) other than those provided under the terms of such plan; or
(B) to prevent such a plan from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.
(3) **Construction** — For purposes of paragraph (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for such enrollment.
**(b) In premium contributions**
(1) **In general** — A group health plan may not require any individual (as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a similarly situated individual enrolled in the plan on the basis of any factor described in subsection (a)(1) in relation to the individual or to an individu
Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 9802
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Group health plan coverage pursuant to medical child support orders**
(1) **In general** — Each group health plan shall provide benefits in accordance with the applicable requirements of any qualified medical child support order. A qualified medical child support order with respect to any participant or beneficiary shall be deemed to apply to each group health plan which has received such order, from which the participant or beneficiary is eligible to receive benefits, and with respect to which the requirements of paragraph (4) are met.
(2) **Definitions** — For purposes of this subsection—
(A) *Qualified medical child support order* — The term “qualified medical child support order” means a medical child support order—
(i) which creates or recognizes the existence of an alternate recipient’s right to, or assigns to an alternate recipient the right to, receive benefits for which a participant or beneficiary is eligible under a group health plan, and
(ii) with respect to which the requirements of paragraphs (3) and (4) are met.
(B) *Medical child support order* — The term “medical child support order” means any judgment, decree, or order (including approval of a settlement agreement) which—
(i) provides for child support with respect to a child of a participant under a group health plan or provides for health benefit coverage to such a child, is made pursuant to a State domestic relations law (including a community property law), and relates to benefits under such plan, or
(ii) is made pursuant to a law relating to medical child support described in section 1908 of the Social Security Act [[42 U.S.C. 1396g–1](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396g–1&num=0&edition=prelim)] (as added by section 13
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Federal law — U.S. Code and appendices · legal_authorities
**(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** 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)(1).
**(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** — 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)(4) if the b
Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 9831
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Purpose** The purpose of this section is to enable the Secretary to ensure to the maximum extent feasible, in any emergency area and during an emergency period (as defined in subsection (g)(1))—
(1) that sufficient health care items and services are available to meet the needs of individuals in such area enrolled in the programs under subchapters XVIII, XIX, and XXI; and
(2) that health care providers (as defined in subsection (g)(2)) that furnish such items and services in good faith, but that are unable to comply with one or more requirements described in subsection (b), may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse.
**(b) Secretarial authority** To the extent necessary to accomplish the purpose specified in subsection (a), the Secretary is authorized, subject to the provisions of this section, to temporarily waive or modify the application of, with respect to health care items and services furnished by a health care provider (or classes of health care providers) in any emergency area (or portion of such an area) during any portion of an emergency period, the requirements of subchapters XVIII, XIX, or XXI, or any regulation thereunder (and the requirements of this subchapter other than this section, and regulations thereunder, insofar as they relate to such subchapters), pertaining to—
(1)
(A) conditions of participation or other certification requirements for an individual health care provider or types of providers,
(B) program participation and similar requirements for an individual health care provider or types of providers, and
(C) pre-approval requirements;
(2) requirements that physicians and other health care professionals be licensed in the State
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Federal law — U.S. Code and appendices · legal_authorities
**(a) In general** A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for—
(1) evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force;
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and 11 So in original.
(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.1
(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.1
(5) for the purposes of this chapter, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.
**(b) Interval**
(1) **In general** — The Secretary shall establish a minimum interval between the date on which a recommendation descr
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300gg–13
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