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26 U.S.C. § 9802 — Prohibiting discrimination against individual participants and beneficiaries based on health status
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
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Source file: Laws/federal/codes/united-states-code/title-26/section-9802-prohibiting-discrimination-against-individual-participants-and-beneficia--a618492f73.md
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Source location: Title 26, Chapter 100, § 9802; chapter-100-group-health-plan-requirements.md
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**(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 individual enrolled under the plan as a dependent of the individual.
(2) **Construction** — Nothing in paragraph (1) shall be construed—
(A) to restrict the amount that an employer may be charged for coverage under a group health plan except as provided in paragraph (3); or
(B) to prevent a group health plan from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
(3) **No group-based discrimination on basis of genetic information**
(A) *In general* — For purposes of this section, a group health plan may not adjust premium or contribution amounts for the group covered under such plan on the basis of genetic information.
(B) *Rule of construction* — Nothing in subparagraph (A) or in paragraphs (1) and (2) of subsection (d) shall be construed to limit the ability of a group health plan to increase the premium for an employer based on the manifestation of a disease or disorder of an individual who is enrolled in the plan. In such case, the manifestation of a disease or disorder in one individual cannot also be used as genetic information about other group members and to further increase the premium for the employer.
**(c) Genetic testing**
(1) **Limitation on requesting or requiring genetic testing** — A group health plan may not request or require an individual or a family member of such individual to undergo a genetic test.
(2) **Rule of construction** — Paragraph (1) shall not be construed to limit the authority of a health care professional who is providing health care services to an individual to request that such individual undergo a genetic test.
(3) **Rule of construction regarding payment**
(A) *In general* — Nothing in paragraph (1) shall be construed to preclude a group health plan from obtaining and using the results of a genetic test in making a determination regarding payment (as such term is defined for the purposes of applying the regulations promulgated by the Secretary of Health and Human Services under part C of title XI of the Social Security Act and section 264 of the Health Insurance Portability and Accountability Act of 1996, as may be revised from time to time) consistent with subsection (a).
(B) *Limitation* — For purposes of subparagraph (A), a group health plan may request only the minimum amount of information necessary to accomplish the intended purpose.
(4) **Research exception** — Notwithstanding paragraph (1), a group health plan may request, but not require, that a participant or beneficiary undergo a genetic test if each of the following conditions is met:
(A) The request is made pursuant to research that complies with part 46 of title 45, Code of Federal Regulations, or equivalent Federal regulations, and any applicable State or local law or regulations for the protection of human subjects in research.
(B) The plan clearly indicates to each participant or beneficiary, or in the case of a minor child, to the legal guardian of such beneficiary, to whom the request is made that—
(i) compliance with the request is voluntary; and
(ii) non-compliance will have no effect on enrollment status or premium or contribution amounts.
(C) No genetic information collected or acquired under this paragraph shall be used for underwriting purposes.
(D) The plan notifies the Secretary in writing that the plan is conducting activities pursuant to the exception provided for under this paragraph, including a description of the activities conducted.
(E) The plan complies with such other conditions as the Secretary may by regulation require for activities conducted under this paragraph.
**(d) Prohibition on collection of genetic information**
(1) **In general** — A group health plan shall not request, require, or purchase genetic information for underwriting purposes (as defined in section 9832).
(2) **Prohibition on collection of genetic information prior to enrollment** — A group health plan shall not request, require, or purchase genetic information with respect to any individual prior to such individual’s enrollment under the plan or in connection with such enrollment.
(3) **Incidental collection** — If a group health plan obtains genetic information incidental to the requesting, requiring, or purchasing of other information concerning any individual, such request, requirement, or purchase shall not be considered a violation of paragraph (2) if such request, requirement, or purchase is not in violation of paragraph (1).
**(e) Application to all plans** The provisions of subsections (a)(1)(F), (b)(3), (c), and (d) and subsection (b)(1) and section 9801 with respect to genetic information, shall apply to group health plans without regard to section 9831(a)(2).
**(f) Special rules for church plans** A church plan (as defined in section 414(e)) shall not be treated as failing to meet the requirements of this section solely because such plan requires evidence of good health for coverage of—
(1) both any employee of an employer with 10 or less employees (determined without regard to section 414(e)(3)(C)) and any self-employed individual, or
(2) any individual who enrolls after the first 90 days of initial eligibility under the plan.
This subsection shall apply to a plan for any year only if the plan included the provisions described in the preceding sentence on July 15, 1997, and at all times thereafter before the beginning of such year.
**(g) Genetic information of a fetus or embryo** Any reference in this chapter to genetic information concerning an individual or family member of an individual shall—
(1) with respect to such an individual or family member of an individual who is a pregnant woman, include genetic information of any fetus carried by such pregnant woman; and
(2) with respect to an individual or family member utilizing an assisted reproductive technology, include genetic information of any embryo legally held by the individual or family member.
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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
For the imposition of tax on any failure of a group health plan to meet the requirements of this chapter, see section 4980D.
Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 9834
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Standards to enable electronic exchange**
(1) **In general** — The Secretary shall adopt standards for transactions, and data elements for such transactions, to enable health information to be exchanged electronically, that are appropriate for—
(A) the financial and administrative transactions described in paragraph (2); and
(B) other financial and administrative transactions determined appropriate by the Secretary, consistent with the goals of improving the operation of the health care system and reducing administrative costs, and subject to the requirements under paragraph (5).
(2) **Transactions** — The transactions referred to in paragraph (1)(A) are transactions with respect to the following:
(A) Health claims or equivalent encounter information.
(B) Health claims attachments.
(C) Enrollment and disenrollment in a health plan.
(D) Eligibility for a health plan.
(E) Health care payment and remittance advice.
(F) Health plan premium payments.
(G) First report of injury.
(H) Health claim status.
(I) Referral certification and authorization.
(J) Electronic funds transfers.
(3) **Accommodation of specific providers** — The standards adopted by the Secretary under paragraph (1) shall accommodate the needs of different types of health care providers.
(4) **Requirements for financial and administrative transactions**
(A) *In general* — The standards and associated operating rules adopted by the Secretary shall—
(i) to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;
(ii) be comprehensive, requiring minimal augmentation by paper or other communications;
(iii) provide for timely acknowledg
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1320d–2
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Federal law — U.S. Code and appendices · legal_authorities
This chapter may be cited as the “Social Security Act”.
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1305
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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
Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 9832
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Federal law — U.S. Code and appendices · legal_authorities
In this chapter:
(1) **Commission** — The term “Commission” means the Equal Employment Opportunity Commission as created by [section 2000e–4 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2000e-4&num=0&edition=prelim).
(2) **Employee; employer; employment agency; labor organization; member**
(A) *In general* — The term “employee” means—
(i) an employee (including an applicant), as defined in [section 2000e(f) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2000e/f&num=0&edition=prelim);
(ii) a State employee (including an applicant) described in [section 2000e–16c(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2000e–16c/a&num=0&edition=prelim);
(iii) a covered employee (including an applicant), as defined in [section 1301 of title 2](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title2-section1301&num=0&edition=prelim);
(iv) a covered employee (including an applicant), as defined in [section 411(c) of title 3](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title3-section411/c&num=0&edition=prelim); or
(v) an employee or applicant to which [section 2000e–16(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2000e–16/a&num=0&edition=prelim) applies.
(B) *Employer* — The term “employer” means—
(i) an employer (as defined in [section 2000e(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2000e/b&num=0&edition=prelim));
(ii) an entity employing a State employee described in [section 2000e–16c(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section2
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 2000ff
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Federal law — U.S. Code and appendices · legal_authorities
**(a) Limitation on application of provisions relating to group health plans**
(1) **In general** — The requirements of subparts 1 and 2 11 See References in Text note below. and part D shall apply with respect to group health plans only—
(A) subject to paragraph (2), in the case of a plan that is a nonfederal governmental plan, and
(B) with respect to health insurance coverage offered in connection with a group health plan (including such a plan that is a church plan or a governmental plan).
(2) **Treatment of non-Federal governmental plans**
(A) *Election to be excluded* — Except as provided in subparagraph (D) or (E), if the plan sponsor of a nonfederal governmental plan which is a group health plan to which the provisions of subparts 1 and 2 1 otherwise apply makes an election under this subparagraph (in such form and manner as the Secretary may by regulations prescribe), then the requirements of such subparts insofar as they apply directly to group health plans (and not merely to group health insurance coverage) shall not apply to such governmental plans for such period except as provided in this paragraph.
(B) *Period of election* — An election under subparagraph (A) shall apply—
(i) for a single specified plan year, or
(ii) in the case of a plan provided pursuant to a collective bargaining agreement, for the term of such agreement.
An election under clause (i) may be extended through subsequent elections under this paragraph.
(C) *Notice to enrollees* — Under such an election, the plan shall provide for—
(i) notice to enrollees (on an annual basis and at the time of enrollment under the plan) of the fact and consequences of such election, and
(ii) certification and disclosure of creditable coverage under the plan with resp
Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 300gg–21
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Federal law — U.S. Code and appendices · legal_authorities
Page 4177
TITLE 26—INTERNAL REVENUE CODE
§ 9802
sistance provided on or after that date, with certain ex-
ceptions, see section 3 of Pub. L. 111–3, set out as an Ef-
fective Date note under section 1396 of Title 42, The
Public Health and Welfare.
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105–34 applicable with respect
to group health plans for plan years beginning on or
after Jan. 1, 1998, see section 1531(c) of Pub. L. 105–34,
set out as a note under section 4980D of this title.
EFFECTIVE DATE
Pub. L. 104–191, title IV, § 401(c), Aug. 21, 1996, 110
Stat. 2082, provided that:
‘‘(1) IN GENERAL.—The amendments made by this sec-
tion [enacting this subtitle] shall apply to plan years
beginning after June 30, 1997.
‘‘(2) DETERMINATION OF CREDITABLE COVERAGE.—
‘‘(A) PERIOD OF COVERAGE.—
‘‘(i) IN GENERAL.—Subject to clause (ii), no period
before July 1, 1996, shall be taken into account
under chapter 100 of the Internal Revenue Code of
1986 (as added by this section) in determining cred-
itable coverage.
‘‘(ii) SPECIAL
RULE
FOR
CERTAIN
PERIODS.—The
Secretary of the Treasury, consistent with section
104 [42 U.S.C. 300gg–92 note], shall provide for a
process whereby individuals who need to establish
creditable coverage for periods before July 1, 1996,
and who would have such coverage credited but for
clause (i) may be given credit for creditable cov-
erage for such periods through the presentation of
documents or other means.
‘‘(B) CERTIFICATIONS, ETC.—
‘‘(i) IN GENERAL.—Subject to clauses (ii) and (iii),
subsection (e) of section 9801 of the Internal Rev-
enue Code of 1986 (as added by this section) shall
apply to events occurring after June 30, 1996.
‘‘(ii) NO CERTIFICATION REQUIRED TO BE PROVIDED
BEFORE JUNE 1, 1997.—In no case is a ce
Source: Supplied 2024 U.S. Code historical extraction · 26 U.S.C. § 9802
Stored review status: historical_2024_not_currentness_verified. Same stored citation; legal effect and authority still require review.