29 U.S.C. § 1181 — Increased portability through limitation

Page 571 TITLE 29—LABOR § 1181 section 13822 [13623] of the Omnibus Budget Reconcili- ation Act of 1993 [Pub. L. 103–66]). ‘‘(5) PROCEDURAL REQUIREMENTS.— ‘‘(A) TIMELY NOTIFICATIONS AND DETERMINA- TIONS.—In the case of any medical child support order received by a church group health plan— ‘‘(i) the plan administrator shall promptly no- tify the participant and each alternate recipient of the receipt of such order and the plan’s proce- dures for determining whether medical child sup- port orders are qualified medical child support or- ders; and ‘‘(ii) within a reasonable period after receipt of such order, the plan administrator shall deter- mine whether such order is a qualified medical child support order and notify the participant and each alternate recipient of such determination. ‘‘(B) ESTABLISHMENT OF PROCEDURES FOR DETER- MINING QUALIFIED STATUS OF ORDERS.—Each church group health plan shall establish reasonable proce- dures to determine whether medical child support orders are qualified medical child support orders and to administer the provision of benefits under such qualified orders. Such procedures— ‘‘(i) shall be in writing; ‘‘(ii) shall provide for the notification of each person specified in a medical child support order as eligible to receive benefits under the plan (at the address included in the medical child support order) of such procedures promptly upon receipt by the plan of the medical child support order; and ‘‘(iii) shall permit an alternate recipient to des- ignate a representative for receipt of copies of no- tices that are sent to the alternate recipient with respect to a medical child support order. ‘‘(C) NATIONAL MEDICAL SUPPORT NOTICE DEEMED TO BE A QUALIFIED MEDICAL CHILD SUPPORT ORDER.— ‘‘(i) IN GENERAL.—If the plan administrator of any church group health plan which is main- tained by the employer of a parent of a child or to which such an employer contributes receives an appropriately completed National Medical Support Notice promulgated pursuant to sub- section (b) of this section [section 401(b) of Pub. L. 105–200, 42 U.S.C. 651 note] in the case of such child, and the Notice meets the requirements of paragraphs (3) and (4) of this subsection, the No- tice shall be deemed to be a qualified medical child support order in the case of such child. ‘‘(ii) ENROLLMENT OF CHILD IN PLAN.—In any case in which an appropriately completed Na- tional Medical Support Notice is issued in the case of a child of a participant under a church group health plan who is a parent of the child, and the Notice is deemed under clause (i) to be a qualified medical child support order, the plan ad- ministrator, within 40 business days after the date of the Notice, shall— ‘‘(I) notify the State agency issuing the No- tice with respect to such child whether cov- erage of the child is available under the terms of the plan and, if so, whether such child is cov- ered under the plan and either the effective date of the coverage or any steps necessary to be taken by the custodial parent (or by the official of a State or political subdivision thereof sub- stituted for the name of such child pursuant to paragraph (3)(A)) to effectuate the coverage; and ‘‘(II) provide to the custodial parent (or such substituted official) a description of the cov- erage available and any forms or documents necessary to effectuate such coverage. ‘‘(iii) RULE OF CONSTRUCTION.—Nothing in this subparagraph shall be construed as requiring a church group health plan, upon receipt of a Na- tional Medical Support Notice, to provide bene- fits under the plan (or eligibility for such bene- fits) in addition to benefits (or eligibility for ben- efits) provided under the terms of the plan as of immediately before receipt of such Notice. ‘‘(6) DIRECT PROVISION OF BENEFITS PROVIDED TO AL- TERNATE RECIPIENTS.—Any payment for benefits made by a church group health plan pursuant to a medical child support order in reimbursement for expenses paid by an alternate recipient or an alternate recipi- ent’s custodial parent or legal guardian shall be made to the alternate recipient or the alternate recipient’s custodial parent or legal guardian. ‘‘(7) PAYMENT TO STATE OFFICIAL TREATED AS SATIS- FACTION OF PLAN’S OBLIGATION TO MAKE PAYMENT TO ALTERNATE RECIPIENT.—Payment of benefits by a church group health plan to an official of a State or a political subdivision thereof whose name and ad- dress have been substituted for the address of an al- ternate recipient in a medical child support order, pursuant to paragraph (3)(A), shall be treated, for purposes of this subsection and part D of title IV of the Social Security Act [42 U.S.C. 651 et seq.], as pay- ment of benefits to the alternate recipient. ‘‘(8) EFFECTIVE DATE.—The provisions of this sub- section shall take effect on the date of the issuance of interim regulations pursuant to subsection (b)(4) of this section [section 401(b)(4) of Pub. L. 105–200, 42 U.S.C. 651 note]. ‘‘(g) REPORT AND RECOMMENDATIONS REGARDING THE ENFORCEMENT OF QUALIFIED MEDICAL CHILD SUPPORT ORDERS.—Not later than 8 months after the issuance of the report to the Congress pursuant to subsection (a)(5) [section 401(a)(5) of Pub. L. 105–200, 42 U.S.C. 651 note], the Secretary of Health and Human Services and the Secretary of Labor shall jointly submit to each House of the Congress a report containing recommendations for appropriate legislation to improve the effectiveness of, and enforcement of, qualified medical child support orders under the provisions of subsection (f) of this sec- tion and section 609(a) of the Employee Retirement In- come Security Act of 1974 (29 U.S.C. 1169(a)).’’ PLAN AMENDMENTS NOT REQUIRED UNTIL JANUARY 1, 1994 For provisions setting forth circumstances under which any amendment to a plan required to be made by an amendment made by section 4301(d) of Pub. L. 103–66 shall not be required to be made before the first plan year beginning on or after Jan. 1, 1994, see section 4301(d) of Pub. L. 103–66, set out as an Effective Date of 1993 Amendment note under section 1021 of this title. PART 7—GROUP HEALTH PLAN REQUIREMENTS Subpart A—Requirements Relating to Portability, Access, and Renewability § 1181. Increased portability through limitation on preexisting condition exclusions (a) Limitation on preexisting condition exclusion period; crediting for periods of previous cov- erage Subject to subsection (d), a group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a pre- existing 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 ad- vice, diagnosis, care, or treatment was rec- ommended or received within the 6-month pe- riod 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 condi- tion exclusion is reduced by the aggregate of Page 572 TITLE 29—LABOR § 1181 the periods of creditable coverage (if any, as defined in subsection (c)(1)) applicable to the participant or beneficiary as of the enrollment date. (b) Definitions For purposes of this part— (1) Preexisting condition exclusion (A) In general The term ‘‘preexisting condition exclu- sion’’ 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 en- rollment for such coverage, whether or not any medical advice, diagnosis, care, or treat- ment was recommended or received before such date. (B) Treatment of genetic information 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 re- spect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for such enrollment. (3) Late enrollee The term ‘‘late enrollee’’ means, with re- spect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during— (A) the first period in which the individual is eligible to enroll under the plan, or (B) a special enrollment period under sub- section (f). (4) Waiting period The term ‘‘waiting period’’ means, with re- spect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with re- spect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. (c) Rules relating to crediting previous coverage (1) ‘‘Creditable coverage’’ defined For purposes of this part, the term ‘‘cred- itable coverage’’ means, with respect to an in- dividual, coverage of the individual under any of the following: (A) A group health plan. (B) Health insurance coverage. (C) Part A or part B of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq.; 1395j et seq.]. (D) Title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], other than coverage consisting solely of benefits under section 1928 [42 U.S.C. 1396s]. (E) Chapter 55 of title 10. (F) A medical care program of the Indian Health Service or of a tribal organization. (G) A State health benefits risk pool. (H) A health plan offered under chapter 89 of title 5. (I) A public health plan (as defined in regu- lations). (J) A health benefit plan under section 2504(e) of title 22. Such term does not include coverage con- sisting solely of coverage of excepted benefits (as defined in section 1191b(c) of this title). (2) Not counting periods before significant breaks in coverage (A) In general A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage. (B) Waiting period not treated as a break in coverage For purposes of subparagraph (A) and sub- section (d)(4), any period that an individual is in a waiting period for any coverage under a group health plan (or for group health in- surance coverage) or is in an affiliation pe- riod (as defined in subsection (g)(2)) shall not be taken into account in determining the continuous period under subparagraph (A). (C) TAA-eligible individuals In the case of plan years beginning before January 1, 2014— (i) TAA pre-certification period rule In the case of a TAA-eligible individual, the period beginning on the date the indi- vidual has a TAA-related loss of coverage and ending on the date that is 7 days after the date of the issuance by the Secretary (or by any person or entity designated by the Secretary) of a qualified health insur- ance costs credit eligibility certificate for such individual for purposes of section 7527 of title 26 shall not be taken into account in determining the continuous period under subparagraph (A). (ii) Definitions The terms ‘‘TAA-eligible individual’’ and ‘‘TAA-related loss of coverage’’ have the meanings given such terms in section 1165(b)(4) of this title. (3) Method of crediting coverage (A) Standard method Except as otherwise provided under sub- paragraph (B), for purposes of applying sub- section (a)(3), a group health plan, and a health insurance issuer offering group health insurance coverage, shall count a pe- riod of creditable coverage without regard to the specific benefits covered during the pe- riod. (B) Election of alternative method A group health plan, or a health insurance issuer offering group health insurance cov- erage, may elect to apply subsection (a)(3) based on coverage of benefits within each of several classes or categories of benefits spec- ified in regulations rather than as provided Page 573 TITLE 29—LABOR § 1181 under subparagraph (A). Such election shall be made on a uniform basis for all partici- pants and beneficiaries. Under such election a group health plan or issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category. (C) Plan notice In the case of an election with respect to a group health plan under subparagraph (B) (whether or not health insurance coverage is provided in connection with such plan), the plan shall— (i) prominently state in any disclosure statements concerning the plan, and state to each enrollee at the time of enrollment under the plan, that the plan has made such election, and (ii) include in such statements a descrip- tion of the effect of this election. (4) Establishment of period Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in sub- section (e) or in such other manner as may be specified in regulations. (d) Exceptions (1) Exclusion not applicable to certain newborns Subject to paragraph (4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not im- pose any preexisting condition exclusion in the case of an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable cov- erage. (2) Exclusion not applicable to certain adopted children Subject to paragraph (4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not im- pose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period be- ginning on the date of the adoption or place- ment for adoption, is covered under creditable coverage. The previous sentence shall not apply to coverage before the date of such adop- tion or placement for adoption. (3) Exclusion not applicable to pregnancy A group health plan, and health insurance issuer offering group health insurance cov- erage, may not impose any preexisting condi- tion exclusion relating to pregnancy as a pre- existing condition. (4) Loss if break in coverage Paragraphs (1) and (2) shall no longer apply to an individual after the end of the first 63- day period during all of which the individual was not covered under any creditable cov- erage. (e) Certifications and disclosure of coverage (1) Requirement for certification of period of creditable coverage (A) In general A group health plan, and a health insur- ance issuer offering group health insurance coverage, shall provide the certification de- scribed in subparagraph (B)— (i) at the time an individual ceases to be covered under the plan or otherwise be- comes covered under a COBRA continu- ation provision, (ii) in the case of an individual becoming covered under such a provision, at the time the individual ceases to be covered under such provision, and (iii) on the request on behalf of an indi- vidual made not later than 24 months after the date of cessation of the coverage de- scribed in clause (i) or (ii), whichever is later. The certification under clause (i) may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provi- sion. (B) Certification The certification described in this sub- paragraph is a written certification of— (i) the period of creditable coverage of the individual under such plan and the coverage (if any) under such COBRA con- tinuation provision, and (ii) the waiting period (if any) (and affili- ation period, if applicable) imposed with respect to the individual for any coverage under such plan. (C) Issuer compliance To the extent that medical care under a group health plan consists of group health insurance coverage, the plan is deemed to have satisfied the certification requirement under this paragraph if the health insurance issuer offering the coverage provides for such certification in accordance with this paragraph. (2) Disclosure of information on previous bene- fits In the case of an election described in sub- section (c)(3)(B) by a group health plan or health insurance issuer, if the plan or issuer enrolls an individual for coverage under the plan and the individual provides a certifi- cation of coverage of the individual under paragraph (1)— (A) upon request of such plan or issuer, the entity which issued the certification pro- vided by the individual shall promptly dis- close to such requesting plan or issuer infor- mation on coverage of classes and categories of health benefits available under such enti- ty’s plan or coverage, and (B) such entity may charge the requesting plan or issuer for the reasonable cost of dis- closing such information. (3) Regulations The Secretary shall establish rules to pre- vent an entity’s failure to provide information Page 574 TITLE 29—LABOR § 1181 under paragraph (1) or (2) with respect to pre- vious coverage of an individual from adversely affecting any subsequent coverage of the indi- vidual under another group health plan or health insurance coverage. (f) Special enrollment periods (1) Individuals losing other coverage A group health plan, and a health insurance issuer offering group health insurance cov- erage in connection with a group health plan, shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the plan (or a dependent of such an employee if the dependent is eligible, but not enrolled, for coverage under such terms) to enroll for coverage under the terms of the plan if each of the following conditions is met: (A) The employee or dependent was cov- ered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or de- pendent. (B) The employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or issuer (if applicable) re- quired such a statement at such time and provided the employee with notice of such requirement (and the consequences of such requirement) at such time. (C) The employee’s or dependent’s cov- erage described in subparagraph (A)— (i) was under a COBRA continuation pro- vision and the coverage under such provi- sion was exhausted; or (ii) was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employ- ment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated. (D) Under the terms of the plan, the em- ployee requests such enrollment not later than 30 days after the date of exhaustion of coverage described in subparagraph (C)(i) or termination of coverage or employer con- tribution described in subparagraph (C)(ii). (2) For dependent beneficiaries (A) In general If— (i) a group health plan makes coverage available with respect to a dependent of an individual, (ii) the individual is a participant under the plan (or has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but for a failure to enroll during a previous enrollment period), and (iii) a person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption, the group health plan shall provide for a de- pendent special enrollment period described in subparagraph (B) during which the person (or, if not otherwise enrolled, the individual) may be enrolled under the plan as a depend- ent of the individual, and in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a depend- ent of the individual if such spouse is other- wise eligible for coverage. (B) Dependent special enrollment period A dependent special enrollment period under this subparagraph shall be a period of not less than 30 days and shall begin on the later of— (i) the date dependent coverage is made available, or (ii) the date of the marriage, birth, or adoption or placement for adoption (as the case may be) described in subparagraph (A)(iii). (C) No waiting period If an individual seeks to enroll a depend- ent during the first 30 days of such a depend- ent special enrollment period, the coverage of the dependent shall become effective— (i) in the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received; (ii) in the case of a dependent’s birth, as of the date of such birth; or (iii) in the case of a dependent’s adoption or placement for adoption, the date of such adoption or placement for adoption. (3) Special rules for application in case of Med- icaid and CHIP (A) In general A group health plan, and a health insur- ance issuer offering group health insurance coverage in connection with a group health plan, shall permit an employee who is eligi- ble, but not enrolled, for coverage under the terms of the plan (or a dependent of such an employee if the dependent is eligible, but not enrolled, for coverage under such terms) to enroll for coverage under the terms of the plan if either of the following conditions is met: (i) Termination of Medicaid or CHIP cov- erage The employee or dependent is covered under a Medicaid plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] or under a State child health plan under title XXI of such Act [42 U.S.C. 1397aa et seq.] and coverage of the em- ployee or dependent under such a plan is terminated as a result of loss of eligibility for such coverage and the employee re- quests coverage under the group health plan (or health insurance coverage) not later than 60 days after the date of termi- nation of such coverage. (ii) Eligibility for employment assistance under Medicaid or CHIP The employee or dependent becomes eli- gible for assistance, with respect to cov- erage under the group health plan or health insurance coverage, under such Page 575 TITLE 29—LABOR § 1181 Medicaid plan or State child health plan (including under any waiver or demonstra- tion project conducted under or in relation to such a plan), if the employee requests coverage under the group health plan or health insurance coverage not later than 60 days after the date the employee or de- pendent is determined to be eligible for such assistance. (B) Coordination with Medicaid and CHIP (i) Outreach to employees regarding avail- ability of Medicaid and CHIP coverage (I) In general Each employer that maintains a group health plan in a State that provides med- ical assistance under a State Medicaid plan under title XIX of the Social Secu- rity Act, or child health assistance under a State child health plan under title XXI of such Act, in the form of premium as- sistance for the purchase of coverage under a group health plan, shall provide to each employee a written notice in- forming the employee of potential oppor- tunities then currently available in the State in which the employee resides for premium assistance under such plans for health coverage of the employee or the employee’s dependents. (II) Model notice Not later than 1 year after February 4, 2009, the Secretary and the Secretary of Health and Human Services, in consulta- tion with Directors of State Medicaid agencies under title XIX of the Social Security Act and Directors of State CHIP agencies under title XXI of such Act, shall jointly develop national and State-specific model notices for purposes of subparagraph (A). The Secretary shall provide employers with such model no- tices so as to enable employers to timely comply with the requirements of sub- paragraph (A). Such model notices shall include information regarding how an employee may contact the State in which the employee resides for addi- tional information regarding potential opportunities for such premium assist- ance, including how to apply for such as- sistance. (III) Option to provide concurrent with provision of plan materials to em- ployee An employer may provide the model notice applicable to the State in which an employee resides concurrent with the furnishing of materials notifying the em- ployee of health plan eligibility, concur- rent with materials provided to the em- ployee in connection with an open season or election process conducted under the plan, or concurrent with the furnishing of the summary plan description as pro- vided in section 1024(b) of this title. (ii) Disclosure about group health plan benefits to States for Medicaid and CHIP eligible individuals In the case of a participant or bene- ficiary of a group health plan who is cov- ered under a Medicaid plan of a State under title XIX of the Social Security Act or under a State child health plan under title XXI of such Act, the plan adminis- trator of the group health plan shall dis- close to the State, upon request, informa- tion about the benefits available under the group health plan in sufficient specificity, as determined under regulations of the Secretary of Health and Human Services in consultation with the Secretary that re- quire use of the model coverage coordina- tion disclosure form developed under sec- tion 311(b)(1)(C) of the Children’s Health Insurance Program Reauthorization Act of 2009, so as to permit the State to make a determination (under paragraph (2)(B), (3), or (10) of section 2105(c) of the Social Secu- rity Act [42 U.S.C. 1397ee(c)(2)(B), (3), (10)] or otherwise) concerning the cost-effec- tiveness of the State providing medical or child health assistance through premium assistance for the purchase of coverage under such group health plan and in order for the State to provide supplemental ben- efits required under paragraph (10)(E) of such section or other authority. (g) Use of affiliation period by HMOs as alter- native to preexisting condition exclusion (1) In general In the case of a group health plan that offers medical care through health insurance cov- erage offered by a health maintenance organi- zation, the plan may provide for an affiliation period with respect to coverage through the organization only if— (A) no preexisting condition exclusion is imposed with respect to coverage through the organization, (B) the period is applied uniformly without regard to any health status-related factors, and (C) such period does not exceed 2 months (or 3 months in the case of a late enrollee). (2) Affiliation period (A) Defined For purposes of this part, the term ‘‘affili- ation period’’ means a period which, under the terms of the health insurance coverage offered by the health maintenance organiza- tion, must expire before the health insur- ance coverage becomes effective. The organi- zation is not required to provide health care services or benefits during such period and no premium shall be charged to the partici- pant or beneficiary for any coverage during the period. (B) Beginning Such period shall begin on the enrollment date. (C) Runs concurrently with waiting periods An affiliation period under a plan shall run concurrently with any waiting period under the plan. Page 576 TITLE 29—LABOR § 1181 (3) Alternative methods A health maintenance organization de- scribed in paragraph (1) may use alternative methods, from those described in such para- graph, to address adverse selection as ap- proved by the State insurance commissioner or official or officials designated by the State to enforce the requirements of part A of title XXVII of the Public Health Service Act [42 U.S.C. 300gg et seq.] for the State involved with respect to such issuer. (Pub. L. 93–406, title I, § 701, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1939; amended Pub. L. 104–204, title VI, § 603(b)(3)(H), Sept. 26, 1996, 110 Stat. 2938; Pub. L. 111–3, title III, § 311(b)(1)(A), Feb. 4, 2009, 123 Stat. 65; Pub. L. 111–5, div. B, title I, § 1899D(b), Feb. 17, 2009, 123 Stat. 426; Pub. L. 111–344, title I, § 114(b), Dec. 29, 2010, 124 Stat. 3615; Pub. L. 112–40, title II, § 242(a)(2), Oct. 21, 2011, 125 Stat. 419.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsecs. (c)(1)(C), (D), (f)(3)(A)(i), (B)(i)(I), (II), (ii), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Parts A and B of title XVIII of the Act are classified generally to parts A (§ 1395c et seq.) and B (§ 1395j et seq.) of subchapter XVIII of chapter 7 of Title 42, The Public Health and Welfare. Titles XIX and XXI of the Act are classified generally to subchapters XIX (§ 1396 et seq.) and XXI (§ 1397aa et seq.), respectively, of chapter 7 of Title 42. For complete classification of this Act to the Code, see section 1305 of Title 42 and Tables. Section 311(b)(1)(C) of the Children’s Health Insur- ance Program Reauthorization Act of 2009, referred to in subsec. (f)(3)(B)(ii), is section 311(b)(1)(C) of Pub. L. 111–3, which is set out as a note under this section. The Public Health Service Act, referred to in subsec. (g)(3), is act July 1, 1944, ch. 373, 58 Stat. 682. Part A of title XXVII of the Act is classified generally to part A (§ 300gg et seq.) of subchapter XXV of chapter 6A of Title 42. For complete classification of this Act to the Code, see Short Title note set out under section 201 of Title 42 and Tables. AMENDMENTS 2011—Subsec. (c)(2)(C). Pub. L. 112–40 substituted ‘‘January 1, 2014’’ for ‘‘February 13, 2011’’ in introduc- tory provisions. 2010—Subsec. (c)(2)(C). Pub. L. 111–344 substituted ‘‘February 13, 2011’’ for ‘‘January 1, 2011’’ in introduc- tory provisions. 2009—Subsec. (c)(2)(C). Pub. L. 111–5 added subpar. (C). Subsec. (f)(3). Pub. L. 111–3 added par. (3). 1996—Subsec. (c)(1). Pub. L. 104–204 made technical amendment to reference in original act which appears in text as reference to section 1191b of this title. Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2011 AMENDMENT Amendment by Pub. L. 112–40 applicable to plan years beginning after Feb. 12, 2011, with transitional rules, see section 242(b) of Pub. L. 112–40, set out as a note under section 9801 of Title 26, Internal Revenue Code. EFFECTIVE DATE OF 2010 AMENDMENT Amendment by Pub. L. 111–344 applicable to plan years beginning after Dec. 31, 2010, see section 114(d) of Pub. L. 111–344, set out as a note under section 9801 of Title 26, Internal Revenue Code. EFFECTIVE DATE OF 2009 AMENDMENT Except as otherwise provided and subject to certain applicability provisions, amendment by Pub. L. 111–5 effective upon the expiration of the 90-day period begin- ning on Feb. 17, 2009, see section 1891 of Pub. L. 111–5, set out as an Effective and Termination Dates of 2009 Amendment note under section 2271 of Title 19, Cus- toms Duties. Amendment by Pub. L. 111–5 applicable to plan years beginning after Feb. 17, 2009, see section 1899D(d) of Pub. L. 111–5, set out as a note under section 9801 of Title 26, Internal Revenue Code. Amendment by Pub. L. 111–3 effective Apr. 1, 2009, and applicable to child health assistance and medical as- 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 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 Pub. L. 104–191, title I, § 101(g), Aug. 21, 1996, 110 Stat. 1953, provided that: ‘‘(1) IN GENERAL.—Except as provided in this section, this section [enacting this part and amending sections 1003, 1021, 1022, 1024, 1132, 1136, and 1144 of this title] (and the amendments made by this section) shall apply with respect to group health plans for plan years begin- ning 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 part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (as added by this section) [this part] in determining cred- itable coverage. ‘‘(ii) SPECIAL RULE FOR CERTAIN PERIODS.—The Secretary of Labor, consistent with section 104 [42 U.S.C. 300gg–92 note], shall provide for a process whereby individuals who need to establish cred- itable 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 701 of the Employee Retire- ment Income Security Act of 1974 [29 U.S.C. 1181(e)](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 certification re- quired to be provided under such subsection before June 1, 1997. ‘‘(iii) CERTIFICATION ONLY ON WRITTEN REQUEST FOR EVENTS OCCURRING BEFORE OCTOBER 1, 1996.—In the case of an event occurring after June 30, 1996, and before October 1, 1996, a certification is not re- quired to be provided under such subsection unless an individual (with respect to whom the certifi- cation is otherwise required to be made) requests such certification in writing. ‘‘(C) TRANSITIONAL RULE.—In the case of an indi- vidual who seeks to establish creditable coverage for any period for which certification is not required be- cause it relates to an event occurring before June 30, 1996— ‘‘(i) the individual may present other credible evi- dence of such coverage in order to establish the pe- riod of creditable coverage; and ‘‘(ii) a group health plan and a health insurance issuer shall not be subject to any penalty or en- forcement action with respect to the plan’s or issuer’s crediting (or not crediting) such coverage if the plan or issuer has sought to comply in good Page 577 TITLE 29—LABOR § 1181 faith with the applicable requirements under the amendments made by this section [enacting this part and amending sections 1003, 1021, 1022, 1024, 1132, 1136, and 1144 of this title]. ‘‘(3) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREE- MENTS.—Except as provided in paragraph (2), in the case of a group health plan maintained pursuant to one or more collective bargaining agreements between em- ployee representatives and one or more employers rati- fied before the date of the enactment of this Act [Aug. 21, 1996], part 7 of subtitle B of title I of Employee Re- tirement Income Security Act of 1974 [this part] (other than section 701(e) thereof [29 U.S.C. 1181(e)]) shall not apply to plan years beginning before the later of— ‘‘(A) the date on which the last of the collective bargaining agreements relating to the plan termi- nates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act), or ‘‘(B) July 1, 1997. For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement re- lating to the plan which amends the plan solely to con- form to any requirement of such part shall not be treated as a termination of such collective bargaining agreement. ‘‘(4) TIMELY REGULATIONS.—The Secretary of Labor, consistent with section 104 [42 U.S.C. 300gg–92 note], shall first issue by not later than April 1, 1997, such reg- ulations as may be necessary to carry out the amend- ments made by this section. ‘‘(5) LIMITATION ON ACTIONS.—No enforcement action shall be taken, pursuant to the amendments made by this section, against a group health plan or health in- surance issuer with respect to a violation of a require- ment imposed by such amendments before January 1, 1998, or, if later, the date of issuance of regulations re- ferred to in paragraph (4), if the plan or issuer has sought to comply in good faith with such require- ments.’’ WORKING GROUP TO DEVELOP MODEL COVERAGE COORDINATION DISCLOSURE FORM Pub. L. 111–3, title III, § 311(b)(1)(C), Feb. 4, 2009, 123 Stat. 68, provided that: ‘‘(i) MEDICAID, CHIP, AND EMPLOYER-SPONSORED COV- ERAGE COORDINATION WORKING GROUP.— ‘‘(I) IN GENERAL.—Not later than 60 days after the date of enactment of this Act [Feb. 4, 2009], the Sec- retary of Health and Human Services and the Sec- retary of Labor shall jointly establish a Medicaid, CHIP, and Employer-Sponsored Coverage Coordina- tion Working Group (in this subparagraph referred to as the ‘Working Group’). The purpose of the Working Group shall be to develop the model coverage coordi- nation disclosure form described in subclause (II) and to identify the impediments to the effective coordina- tion of coverage available to families that include employees of employers that maintain group health plans and members who are eligible for medical as- sistance under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] or child health assistance or other health benefits coverage under title XXI of such Act [42 U.S.C. 1397aa et seq.]. ‘‘(II) MODEL COVERAGE COORDINATION DISCLOSURE FORM DESCRIBED.—The model form described in this subclause is a form for plan administrators of group health plans to complete for purposes of permitting a State to determine the availability and cost-effec- tiveness of the coverage available under such plans to employees who have family members who are eligible for premium assistance offered under a State plan under title XIX or XXI of such Act and to allow for coordination of coverage for enrollees of such plans. Such form shall provide the following information in addition to such other information as the Working Group determines appropriate: ‘‘(aa) A determination of whether the employee is eligible for coverage under the group health plan. ‘‘(bb) The name and contract information of the plan administrator of the group health plan. ‘‘(cc) The benefits offered under the plan. ‘‘(dd) The premiums and cost-sharing required under the plan. ‘‘(ee) Any other information relevant to coverage under the plan. ‘‘(ii) MEMBERSHIP.—The Working Group shall consist of not more than 30 members and shall be composed of representatives of— ‘‘(I) the Department of Labor; ‘‘(II) the Department of Health and Human Serv- ices; ‘‘(III) State directors of the Medicaid program under title XIX of the Social Security Act; ‘‘(IV) State directors of the State Children’s Health Insurance Program under title XXI of the Social Se- curity Act; ‘‘(V) employers, including owners of small busi- nesses and their trade or industry representatives and certified human resource and payroll profes- sionals; ‘‘(VI) plan administrators and plan sponsors of group health plans (as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1167(1)]); ‘‘(VII) health insurance issuers; and ‘‘(VIII) children and other beneficiaries of medical assistance under title XIX of the Social Security Act or child health assistance or other health benefits coverage under title XXI of such Act. ‘‘(iii) COMPENSATION.—The members of the Working Group shall serve without compensation. ‘‘(iv) ADMINISTRATIVE SUPPORT.—The Department of Health and Human Services and the Department of Labor shall jointly provide appropriate administrative support to the Working Group, including technical as- sistance. The Working Group may use the services and facilities of either such Department, with or without reimbursement, as jointly determined by such Depart- ments. ‘‘(v) REPORT.— ‘‘(I) REPORT BY WORKING GROUP TO THE SECRE- TARIES.—Not later than 18 months after the date of the enactment of this Act, the Working Group shall submit to the Secretary of Labor and the Secretary of Health and Human Services the model form de- scribed in clause (i)(II) along with a report containing recommendations for appropriate measures to ad- dress the impediments to the effective coordination of coverage between group health plans and the State plans under titles XIX and XXI of the Social Security Act. ‘‘(II) REPORT BY SECRETARIES TO THE CONGRESS.— Not later than 2 months after receipt of the report pursuant to subclause (I), the Secretaries shall joint- ly submit a report to each House of the Congress re- garding the recommendations contained in the report under such subclause. ‘‘(vi) TERMINATION.—The Working Group shall termi- nate 30 days after the date of the issuance of its report under clause (v).’’ [For definitions of ‘‘CHIP’’ and ‘‘Medicaid’’ as used in section 311(b)(1)(C) of Pub. L. 111–3, set out above, see section 1(c)(1), (2) of Pub. L. 111–3, set out as a Defini- tions note under section 1396 of Title 42, The Public Health and Welfare.] IMPLEMENTATION OF 2009 AMENDMENT Pub. L. 111–3, title III, § 311(b)(1)(D), Feb. 4, 2009, 123 Stat. 69, provided that: ‘‘The Secretary of Labor and the Secretary of Health and Human Services shall de- velop the initial model notices under section 701(f)(3)(B)(i)(II) of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1181(f)(3)(B)(i)(II)], and the Secretary of Labor shall provide such notices to employers, not later than the date that is 1 year after the date of enactment of this Act [Feb. 4, 2009], and each employer shall provide the initial annual notices to such employer’s employees beginning with the first plan year that begins after the date on which such ini- tial model notices are first issued. The model coverage Page 578 TITLE 29—LABOR § 1182 coordination disclosure form developed under subpara- graph (C) [set out above] shall apply with respect to re- quests made by States beginning with the first plan year that begins after the date on which such model coverage coordination disclosure form is first issued.’’ § 1182. Prohibiting discrimination against indi- vidual participants and beneficiaries based on health status (a) In eligibility to enroll (1) In general Subject to paragraph (2), a group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligi- bility) of any individual to enroll under the terms of the plan based on any of the fol- lowing health status-related factors in rela- tion to the individual or a dependent of the in- dividual: (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 vi- olence). (H) Disability. (2) No application to benefits or exclusions To the extent consistent with section 1181 of this title, paragraph (1) shall not be con- strued— (A) to require a group health plan, or group health insurance coverage, to provide particular benefits other than those pro- vided under the terms of such plan or cov- erage, or (B) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situ- ated individuals enrolled in the plan or cov- erage. (3) Construction For purposes of paragraph (1), rules for eligi- bility to enroll under a plan include rules de- fining any applicable waiting periods for such enrollment. (b) In premium contributions (1) In general A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not require any individual (as a condition of en- rollment 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 health status-re- lated factor in relation to the individual or to an individual enrolled under the plan as a de- pendent of the individual. (2) Construction Nothing in paragraph (1) shall be con- strued— (A) to restrict the amount that an em- ployer may be charged for coverage under a group health plan except as provided in paragraph (3); or (B) to prevent a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to pro- grams of health promotion and disease pre- vention. (3) No group-based discrimination on basis of genetic information (A) In general For purposes of this section, a group health plan, and a health insurance issuer offering group health insurance coverage in connection with 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 para- graphs (1) and (2) of subsection (d) shall be construed to limit the ability of a health in- surance issuer offering health insurance cov- erage in connection with 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 can- not 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 ge- netic testing A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, shall not request or require an individual or a family member of such individual to undergo a ge- netic 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 in- dividual to request that such individual under- go a genetic test. (3) Rule of construction regarding payment (A) In general Nothing in paragraph (1) shall be con- strued to preclude a group health plan, or a health insurance issuer offering health in- surance coverage in connection with a group health plan, from obtaining and using the re- sults of a genetic test in making a deter- mination 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 [42 U.S.C. 1320d et seq.] 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).