SEC. 2791 DEFINITIONS.
Title[ Title I\Subtitle A\Sec. 102 Contents
<<NOTE: 42 USC 300gg-91.>> .
``(a) Group Health Plan.--
``(1) Definition.--The term `group health plan' means an
employee welfare benefit plan (as defined in section 3(1) of the
Employee Retirement Income Security Act of 1974) 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, reimbursement, or
otherwise.
``(2) Medical care.--The term `medical care' means amounts
paid for--
``(A) the diagnosis, cure, mitigation, treatment, or
prevention of disease, or amounts paid for the purpose
of affecting any structure or function of the body,
``(B) amounts paid for transportation primarily for
and essential to medical care referred to in
subparagraph (A), and
``(C) amounts paid for insurance covering medical
care referred to in subparagraphs (A) and (B).
``(3) Treatment of certain plans as group health plan for
notice provision.--A program under which creditable coverage
described in subparagraph (C), (D), (E), or (F) of section
2701(c)(1) is provided shall be treated as a group health plan
for purposes of applying section 2701(e).
``(b) Definitions Relating to Health Insurance.--
``(1) Health insurance coverage.--The term `health insurance
coverage' means benefits consisting of medical care (provided
directly, through insurance or reimbursement, or otherwise and
including items and services paid for as medical care) under any
hospital or medical service policy or certificate, hospital or
medical service plan contract, or health maintenance
organization contract offered by a health insurance issuer.
``(2) Health insurance issuer.--The term `health insurance
issuer' means an insurance company, insurance service, or
insurance organization (including a health maintenance
organization, as defined in paragraph (3)) which is licensed to
engage in the business of insurance in a State and which is
subject to State law which regulates insurance (within the
meaning of section 514(b)(2) of the Employee Retirement Income
Security Act of 1974). 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)),
``(B) an organization recognized under State law as
a health maintenance organization, or
``(C) a similar organization regulated under State
law for solvency in the same manner and to the same
extent as such a health maintenance organization.
``(4) Group health insurance coverage.--The term `group
health insurance coverage' means, in connection with a group
health plan, health insurance coverage offered in connection
with such plan.
``(5) Individual health insurance coverage.--The term
`individual health insurance coverage' means health insurance
coverage offered to individuals in the individual market, but
does not include short-term limited duration insurance.
``(c) Excepted Benefits.--For purposes of this title, 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.--
``(1) Applicable state authority.--The term `applicable
State authority' means, with respect to a health insurance
issuer in a State, the State insurance commissioner or official
or officials designated by the State to enforce the requirements
of this title for the State involved with respect to such
issuer.
``(2) Beneficiary.--The term `beneficiary' has the meaning
given such term under section 3(8) of the Employee Retirement
Income Security Act of 1974.
``(3) Bona fide association.--The term `bona fide
association' means, with respect to health insurance coverage
offered in a State, an association which--
``(A) has been actively in existence for at least 5
years;
``(B) has been formed and maintained in good faith
for purposes other than obtaining insurance;
``(C) does not condition membership in the
association on any health status-related factor relating
to an individual (including an employee of an employer
or a dependent of an employee);
``(D) makes health insurance coverage offered
through the association available to all members
regardless of any health status-related factor relating
to such members (or individuals eligible for coverage
through a member);
``(E) does not make health insurance coverage
offered through the association available other than in
connection with a member of the association; and
``(F) meets such additional requirements as may be
imposed under State law.
``(4) COBRA continuation provision.--The term `COBRA
continuation provision' means any of the following:
``(A) Section 4980B of the Internal Revenue Code of
1986, other than subsection (f)(1) of such section
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, other
than section 609 of such Act.
``(C) Title XXII of this Act.
``(5) Employee.--The term `employee' has the meaning given
such term under section 3(6) of the Employee Retirement Income
Security Act of 1974.
``(6) Employer.--The term `employer' has the meaning given
such term under section 3(5) of the Employee Retirement Income
Security Act of 1974, except that such term shall include only
employers of two or more employees.
``(7) Church plan.--The term `church plan' has the meaning
given such term under section 3(33) of the Employee Retirement
Income Security Act of 1974.
``(8) Governmental plan.--(A) The term `governmental plan'
has the meaning given such term under section 3(32) of the
Employee Retirement Income Security Act of 1974 and any Federal
governmental plan.
``(B) Federal governmental plan.--The term `Federal
governmental plan' means a governmental plan established or
maintained for its employees by the Government of the United
States or by any agency or instrumentality of such Government.
``(C) Non-Federal governmental plan.--The term `non-Federal
governmental plan' means a governmental plan that is not a
Federal governmental plan.
``(9) Health status-related factor.--The term `health
status-related factor' means any of the factors described in
section 2702(a)(1).
``(10) Network plan.--The term `network plan' means health
insurance coverage of a health insurance issuer under which the
financing and delivery of medical care (including items and
services paid for as medical care) are provided, in whole or in
part, through a defined set of providers under contract with the
issuer.
``(11) Participant.--The term `participant' has the meaning
given such term under section 3(7) of the Employee Retirement
Income Security Act of 1974.
``(12) Placed for adoption defined.--The term `placement',
or being `placed', for adoption, in connection with any
placement for adoption of a child with any person, means the
assumption and retention by such person of a legal obligation
for total or partial support of such child in anticipation of
adoption of such child. The child's placement with such person
terminates upon the termination of such legal obligation.
``(13) Plan sponsor.--The term `plan sponsor' has the
meaning given such term under section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
``(14) State.--The term `State' means each of the several
States, the District of Columbia, Puerto Rico, the Virgin
Islands, Guam, American Samoa, and the Northern Mariana Islands.
``(e) Definitions Relating to Markets and Small Em-
ployers.--For purposes of this title:
``(1) Individual market.--
``(A) In general.--The term `individual market'
means the market for health insurance coverage offered
to individuals other than in connection with a group
health plan.
``(B) Treatment of very small groups.--
``(i) In general.--Subject to clause (ii),
such terms includes coverage offered in connection
with a group health plan that has fewer than two
participants as current employees on the first day
of the plan year.
``(ii) State exception.--Clause (i) shall not
apply in the case of a State that elects to
regulate the coverage described in such clause as
coverage in the small group market.
``(2) Large employer.--The term `large employer' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 51 employees on business
days during the preceding calendar year and who employs at least 2
employees on the first day of the plan year.
``(3) Large group market.--The term `large group market'
means the health insurance market under which individuals obtain
health insurance coverage (directly or through any arrangement)
on behalf of themselves (and their dependents) through a group
health plan maintained by a large employer.
``(4) Small employer.--The term `small employer' means, in
connection with a group health plan with respect to a calendar
year and a plan year, an employer who employed an average of at
least 2 but not more than 50 employees on business days during
the preceding calendar year and who employs at least 2 employees
on the first day of the plan year.
``(5) Small group market.--The term `small group market'
means the health insurance market under which individuals obtain
health insurance coverage (directly or through any arrangement)
on behalf of themselves (and their dependents) through a group
health plan maintained by a small employer.
``(6) Application of certain rules in determination of
employer size.--For purposes of this subsection--
``(A) Application of aggregation rule for
employers.--all persons treated as a single employer
under subsection (b), (c), (m), or (o) of section 414 of
the Internal Revenue Code of 1986 shall be treated as 1
employer.
``(B) Employers not in existence in preceding
year.--In the case of an employer which was not in
existence throughout the preceding calendar year, the
determination of whether such employer is a small or
large employer shall be based on the average number of
employees that it is reasonably expected such employer
will employ on business days in the current calendar
year.
``(C) Predecessors.--Any reference in this
subsection to an employer shall include a reference to
any predecessor of such employer.
``
Contents
Contents
Prev
Next
Last
