§1191b. Definitions

29 U.S.C. § 1191b

(a)

Group health plan— For purposes of this part—

(1)

In general— The term “group health plan” means an employee 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, reimbursement, 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, 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).

(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 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 1144(b)(2) of this title). 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))),

(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.

(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 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 1395ss(g)(1) of title 42), coverage supplemental to the coverage provided under chapter 55 of title 10, and similar supplemental coverage provided to coverage under a group health plan.

(d)

Other definitions— For purposes of this part—

(1)

COBRA continuation provision— The term “COBRA continuation provision” means any of the following:

(A)

Part 6 of this subtitle.

(B)

Section 4980B of title 26, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.

(C)

Title XXII of the Public Health Service Act [42 U.S.C. 300bb–1 et seq.].

(2)

Health status-related factor— The term “health status-related factor” means any of the factors described in section 1182(a)(1) of this title.

(3)

Network plan— The term “network plan” means health insurance coverage offered by 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.

(4)

Placed for adoption— The term “placement”, or being “placed”, for adoption, has the meaning given such term in section 1169(c)(3)(B) of this title.

(5)

Family member— The term “family member” means, with respect to an individual—

(A)

a dependent (as such term is used for purposes of section 1181(f)(2) of this title) 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).

(6)

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.

(7)

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.

(8)

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.

(9)

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.

Notes, amendments, and revision history

(Pub. L. 93–406, title I, § 733, formerly § 706, as added Pub. L. 104–191, title I, § 101(a), Aug. 21, 1996, 110 Stat. 1949; renumbered § 733, Pub. L. 104–204, title VI, § 603(a)(3), Sept. 26, 1996, 110 Stat. 2935; amended Pub. L. 110–233, title I, § 101(d), May 21, 2008, 122 Stat. 885; Pub. L. 114–255, div. C, title XVIII, § 18001(b)(1), Dec. 13, 2016, 130 Stat. 1343.)

Editorial Notes

References in Text

The Public Health Service Act, referred to in subsec. (d)(1)(C), is act July 1, 1944, ch. 373, 58 Stat. 682. Title XXII of the Act is classified generally to subchapter XX (§ 300bb–1 et seq.) of chapter 6A of Title 42, The Public Health and Welfare. For complete classification of this Act to the Code, see Short Title note set out under section 201 of Title 42 and Tables.

Amendments

2016—Subsec. (a)(1). Pub. L. 114–255 inserted at end “Such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26).”

2008—Subsec. (d)(5) to (9). Pub. L. 110–233 added pars. (5) to (9).

Statutory Notes and Related Subsidiaries

Effective Date of 2016 Amendment

Amendment by Pub. L. 114–255 applicable to plan years beginning after Dec. 31, 2016, see section 18001(b)(3) of Pub. L. 114–255, set out as a note under section 1167 of this title.

Effective Date of 2008 Amendment

Amendment by Pub. L. 110–233 applicable with respect to group health plans for plan years beginning after the date that is one year after May 21, 2008, see section 101(f)(2) of Pub. L. 110–233, set out as a note under section 1132 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.