29 U.S.C. § 1191a — Special rules relating to group health

Page 612 TITLE 29—LABOR § 1191a law of the United States applicable only to the District of Columbia shall be treated as a State law rather than a law of the United States. (2) State The term ‘‘State’’ includes a State, the Northern Mariana Islands, any political sub- divisions of a State or such Islands, or any agency or instrumentality of either. (Pub. L. 93–406, title I, § 731, formerly § 704, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1946; renumbered § 731 and amend- ed Pub. L. 104–204, title VI, § 603(a)(3), (b)(1), Sept. 26, 1996, 110 Stat. 2935, 2937.) Editorial Notes AMENDMENTS 1996—Subsec. (c). Pub. L. 104–204, § 603(b)(1), sub- stituted ‘‘Except as provided in section 1185 of this title, nothing’’ for ‘‘Nothing’’. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1996 AMENDMENT Amendment by Pub. L. 104–204 applicable with re- spect to group health plans for plan years beginning on and after Jan. 1, 1998, see section 603(c) of Pub. L. 104–204, set out as a note under section 1003 of this title. EFFECTIVE DATE Section applicable with respect to group health plans for plan years beginning after June 30, 1997, except as otherwise provided, see section 101(g) of Pub. L. 104–191, set out as a note under section 1181 of this title. § 1191a. Special rules relating to group health plans (a) General exception for certain small group health plans The requirements of this part (other than sec- tion 1185 of this title) shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year if, on the first day of such plan year, such plan has less than 2 par- ticipants who are current employees. (b) Exception for certain benefits The requirements of this part shall not apply to any group health plan (and group health in- surance coverage) in relation to its provision of excepted benefits described in section 1191b(c)(1) of this title. (c) Exception for certain benefits if certain con- ditions met (1) Limited, excepted benefits The requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connec- tion with a group health plan) in relation to its provision of excepted benefits described in section 1191b(c)(2) of this title 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 part shall not apply to any group health plan (and group health insurance coverage offered in connec- tion with a group health plan) in relation to its provision of excepted benefits described in section 1191b(c)(3) of this title if all of the fol- lowing conditions are met: (A) The benefits are provided under a sepa- rate policy, certificate, or contract of insur- ance. (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 part shall not apply to any group health plan (and group health insurance coverage) in relation to its provision of excepted benefits described in sec- tion 1191b(c)(4) of this title if the benefits are provided under a separate policy, certificate, or contract of insurance. (d) Treatment of partnerships For purposes of this part— (1) Treatment as a group health plan Any plan, fund, or program which would not be (but for this subsection) an employee wel- fare benefit plan and which is established or maintained by a partnership, to the extent that such plan, fund, or program provides med- ical care (including items and services paid for as medical care) to present or former partners in the partnership or to their dependents (as defined under the terms of the plan, fund, or program), directly or through insurance, reim- bursement, or otherwise, shall be treated (sub- ject to paragraph (2)) as an employee welfare benefit plan which is a group health plan. (2) Employer In the case of a group health plan, the term ‘‘employer’’ also includes the partnership in relation to any partner. (3) Participants of group health plans In the case of a group health plan, the term ‘‘participant’’ also includes— (A) in connection with a group health plan maintained by a partnership, an individual who is a partner in relation to the partner- ship, or (B) in connection with a group health plan maintained by a self-employed individual (under which one or more employees are par- ticipants), the self-employed individual, if such individual is, or may become, eligible to receive a benefit under the plan or such in- dividual’s beneficiaries may be eligible to re- ceive any such benefit. (Pub. L. 93–406, title I, § 732, formerly § 705, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1948; renumbered § 732 and amend- ed Pub. L. 104–204, title VI, § 603(a)(3), (b)(2), (3)(I)–(L), Sept. 26, 1996, 110 Stat. 2935, 2937, 2938.) Page 613 TITLE 29—LABOR § 1191b Editorial Notes AMENDMENTS 1996—Subsec. (a). Pub. L. 104–204, § 603(b)(2), inserted ‘‘(other than section 1185 of this title)’’ after ‘‘part’’. Subsecs. (b), (c)(1) to (3). Pub. L. 104–204, § 603(b)(3)(I)–(L), made technical amendment to ref- erences in original act which appear in text as ref- erences to section 1191b of this title. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 1996 AMENDMENT Amendment by Pub. L. 104–204 applicable with re- spect to group health plans for plan years beginning on and after Jan. 1, 1998, see section 603(c) of Pub. L. 104–204, set out as a note under section 1003 of this title. EFFECTIVE DATE Section applicable with respect to group health plans for plan years beginning after June 30, 1997, except as otherwise provided, see section 101(g) of Pub. L. 104–191, set out as a note under section 1181 of this title. § 1191b. Definitions (a) Group health plan For purposes of this part— (1) In general The term ‘‘group health plan’’ means an em- ployee welfare benefit plan 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, reim- bursement, or otherwise. Such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26). (2) Medical care The term ‘‘medical care’’ means amounts paid for— (A) the diagnosis, cure, mitigation, treat- ment, or prevention of disease, or amounts paid for the purpose of affecting any struc- ture or function of the body, (B) amounts paid for transportation pri- marily for and essential to medical care re- ferred to in subparagraph (A), and (C) amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B). (b) Definitions relating to health insurance For purposes of this part— (1) Health insurance coverage The term ‘‘health insurance coverage’’ means benefits consisting of medical care (provided directly, through insurance or reim- bursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or cer- tificate, hospital or medical service plan con- tract, 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 para- graph (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 1144(b)(2) of this title). Such term does not include a group health plan. (3) Health maintenance organization The term ‘‘health maintenance organiza- tion’’ means— (A) a federally qualified health mainte- nance organization (as defined in section 1301(a) of the Public Health Service Act (42 U.S.C. 300e(a))), (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 con- nection with such plan. (c) Excepted benefits For purposes of this part, 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 li- ability insurance. (C) Liability insurance, including general li- ability insurance and automobile liability in- surance. (D) Workers’ compensation or similar insur- ance. (E) Automobile medical payment insurance. (F) Credit-only insurance. (G) Coverage for on-site medical clinics. (H) Other similar insurance coverage, speci- fied in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. (2) Benefits not subject to requirements if of- fered 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 of- fered as independent, noncoordinated ben- efits (A) Coverage only for a specified disease or illness. (B) Hospital indemnity or other fixed indem- nity insurance. (4) Benefits not subject to requirements if of- fered as separate insurance policy Medicare supplemental health insurance (as defined under section 1395ss(g)(1) of title 42), coverage supplemental to the coverage pro-