---
kind: "section"
citation: "42 U.S.C. § 300gg–91"
title: "42"
title_heading: "The Public Health and Welfare"
number: "300gg–91"
heading: "Definitions"
release: "119-102"
date: "2026-07-12"
url: "https://uscodex.org/usc/42/300gg-91"
units:
  - "Chapter 6A — Public Health Service"
  - "Subchapter XXV — Requirements Relating to Health Insurance Coverage"
  - "Part C — Definitions; Miscellaneous Provisions"
---

# §300gg–91. Definitions

- (a) **Group health plan—**
  - (1) **Definition—** The term “[group health plan](/usc/42/300bb–8.md?p=1)” means an [employee](#d-5) welfare benefit plan (as defined in section 3(1) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(1)](/usc/29/1002.md?p=1)]) to the extent that the plan provides [medical care](#a-2) (as defined in [paragraph (2)](#a-2)) and including items and [services](/usc/42/201.md?p=a) paid for as [medical care](#a-2)) to [employees](#d-5) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Except for purposes of part C of title XI of the Social Security Act ([42 U.S.C. 1320d](/usc/42/1320d.md) et seq.), such term shall not include any qualified [small employer](#e-4) health reimbursement arrangement (as defined in [section 9831(d)(2) of title 26](/usc/26/9831.md?p=d-2)).
  - (2) **Medical care—** The term “medical care” means amounts paid for—
    - (A) the diagnosis, cure, mitigation, [treatment](/usc/42/11851.md?p=11), 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](#a-2) referred to in [subparagraph (A)](#a-2-A), and
    - (C) amounts paid for insurance covering [medical care](#a-2) referred to in subparagraphs [(A)](#a-2-A) and [(B)](#a-2-B).
  - (3) **Treatment of certain plans as group health plan for notice provision—** A [program](/usc/42/274l–1.md?p=4) under which creditable coverage described in subparagraph [(C)](/usc/42/2701.md), [(D)](/usc/42/2701.md), [(E)](/usc/42/2701.md), or [(F)](/usc/42/2701.md) of section 2701(c)(1)[^1] is provided shall be treated as a [group health plan](/usc/42/300bb–8.md?p=1) for purposes of applying [section 2701(e)](/usc/42/2701.md).[^1]
- (b) **Definitions relating to health insurance—**
  - (1) **Health insurance coverage—** The term “health insurance coverage” means benefits consisting of [medical care](#a-2) (provided directly, through insurance or reimbursement, or otherwise and including items and [services](/usc/42/201.md?p=a) paid for as [medical care](#a-2)) under any [hospital](/usc/42/300s–3.md?p=1) or medical [service](/usc/42/201.md?p=a) policy or certificate, [hospital](/usc/42/300s–3.md?p=1) or medical [service](/usc/42/201.md?p=a) plan contract, or [health maintenance organization](#b-3) contract offered by a [health insurance issuer](#b-2).
  - (2) **Health insurance issuer—** The term “health insurance issuer” means an insurance company, insurance [service](/usc/42/201.md?p=a), or insurance organization (including a [health maintenance organization](#b-3), as defined in [paragraph (3)](#b-3)) which is licensed to engage in the business of insurance in a [State](/usc/42/201.md?p=f) and which is subject to [State](/usc/42/201.md?p=f) law which regulates insurance (within the meaning of section 514(b)(2) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1144(b)(2)](/usc/29/1144.md?p=b-2)]). Such term does not include a [group health plan](/usc/42/300bb–8.md?p=1).
  - (3) **Health maintenance organization—** The term “health maintenance organization” means—
    - (A) a Federally qualified [health maintenance organization](#b-3) (as defined in [section 300e(a) of this title](/usc/42/300e.md?p=a)),
    - (B) an organization recognized under [State](/usc/42/201.md?p=f) law as a [health maintenance organization](#b-3), or
    - (C) a similar organization regulated under [State](/usc/42/201.md?p=f) law for solvency in the same manner and to the same extent as such a [health maintenance organization](#b-3).
  - (4) **Group health insurance coverage—** The term “group health insurance coverage” means, in connection with a [group health plan](/usc/42/300bb–8.md?p=1), [health insurance coverage](#b-1) offered in connection with such plan.
  - (5) **Individual health insurance coverage—** The term “individual health insurance coverage” means [health insurance coverage](#b-1) offered to individuals in the [individual market](#e-1-A), but does not include short-term limited duration insurance.
- (c) **Excepted benefits—** For purposes of this subchapter, 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](/usc/42/201.md?p=d), under which benefits for [medical care](#a-2) 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](/usc/42/201.md?p=d).
  - (3) **Benefits not subject to requirements if offered as independent, noncoordinated benefits—**
    - (A) Coverage only for a specified disease or illness.
    - (B) [Hospital](/usc/42/300s–3.md?p=1) 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 this title](/usc/42/1395ss.md?p=g-1)), coverage supplemental to the coverage provided under [chapter 55](/usc/10/chstA/ptII/ch55.md) of title 10, and similar supplemental coverage provided to coverage under a [group health plan](/usc/42/300bb–8.md?p=1).
- (d) **Other definitions—**
  - (1) **Applicable State authority—** The term “applicable State authority” means, with respect to a [health insurance issuer](#b-2) in a [State](/usc/42/201.md?p=f), the [State](/usc/42/201.md?p=f) insurance commissioner or official or officials designated by the [State](/usc/42/201.md?p=f) to enforce the requirements of this subchapter for the [State](/usc/42/201.md?p=f) involved with respect to such issuer.
  - (2) **Beneficiary—** The term “beneficiary” has the meaning given such term under section 3(8) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(8)](/usc/29/1002.md?p=8)].
  - (3) **Bona fide association—** The term “bona fide association” means, with respect to [health insurance coverage](#b-1) offered in a [State](/usc/42/201.md?p=f), 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](#d-9) relating to an individual (including an [employee](#d-5) of an [employer](#d-6) or a dependent of an [employee](#d-5));
    - (D) makes [health insurance coverage](#b-1) offered through the association available to all members regardless of any [health status-related factor](#d-9) relating to such members (or individuals eligible for coverage through a member);
    - (E) does not make [health insurance coverage](#b-1) 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](/usc/42/201.md?p=f) law.
  - (4) **COBRA continuation provision—** The term “COBRA continuation provision” means any of the following:
    - (A) [Section 4980B of title 26](/usc/26/4980B.md), other than [subsection (f)(1)](/usc/26/4980B.md?p=f-1) of such section insofar as it relates to pediatric vaccines.
    - (B) Part 6 of subtitle B of title I of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1161](/usc/29/1161.md) et seq.], other than [section 609](/usc/42/609.md) of such Act [[29 U.S.C. 1169](/usc/29/1169.md)].
    - (C) Subchapter XX of this chapter.
  - (5) **Employee—** The term “employee” has the meaning given such term under section 3(6) of the Employee Retirement Income Security Act of 1974 [[29 U.S.C. 1002(6)](/usc/29/1002.md?p=6)].
  - (6) **Employer—** The term “employer” has the meaning given such term under section 3(5) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(5)](/usc/29/1002.md?p=5)], except that such term shall include only employers of two or more [employees](#d-5).
  - (7) **Church plan—** The term “church plan” has the meaning given such term under section 3(33) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(33)](/usc/29/1002.md?p=33)].
  - (8) **Governmental plan—**
    - (A) The term “governmental plan” has the meaning given such term under section 3(32) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(32)](/usc/29/1002.md?p=32)] and any [Federal governmental plan](#d-8-B).
    - (B) **Federal governmental plan.—** The term “Federal governmental plan” means a [governmental plan](#d-8-A) established or maintained for its [employees](#d-5) by the Government of the United States or by any [agency](/usc/42/8262.md?p=1) or instrumentality of such Government.
    - (C) **Non-Federal governmental plan.—** The term “non-Federal governmental plan” means a [governmental plan](#d-8-A) that is not a [Federal governmental plan](#d-8-B).
  - (9) **Health status-related factor—** The term “health status-related factor” means any of the factors described in [section 2702(a)(1)](/usc/42/2702.md).[^1]
  - (10) **Network plan—** The term “network plan” means [health insurance coverage](#b-1) of a [health insurance issuer](#b-2) under which the financing and delivery of [medical care](#a-2) (including items and [services](/usc/42/201.md?p=a) paid for as [medical care](#a-2)) are provided, in whole or in part, through a defined set of [providers](/usc/42/299b–21.md?p=8) under contract with the issuer.
  - (11) **Participant—** The term “participant” has the meaning given such term under section 3(7) of the [Employee](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(7)](/usc/29/1002.md?p=7)].
  - (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](#d-5) Retirement Income Security Act of 1974 [[29 U.S.C. 1002(16)(B)](/usc/29/1002.md?p=16-B)].
  - (14) **State—** The term “[State](/usc/42/201.md?p=f)” means each of the several [States](/usc/42/201.md?p=f), the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
  - (15) **Family member—** The term “family member” means, with respect to any individual—
    - (A) a dependent (as such term is used for purposes of [section 2701(f)(2)](/usc/42/2701.md))[^1] 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)](#d-15-A).
  - (16) **Genetic information—**
    - (A) **In general—** The term “genetic information” means, with respect to any individual, information about—
      - (i) such individual’s [genetic tests](#d-17-A),
      - (ii) the [genetic tests](#d-17-A) of [family members](#d-15) of such individual, and
      - (iii) the manifestation of a disease or disorder in [family members](#d-15) 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](#d-18), or participation in [clinical research](/usc/42/284d.md?p=b) which includes [genetic services](#d-18), by such individual or any [family member](#d-15) of such individual.
    - (C) **Exclusions—** The term “[genetic information](#d-16-A)” shall not include information about the sex or age of any individual.
  - (17) **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](#d-17-A)” 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.
  - (18) **Genetic services—** The term “genetic services” means—
    - (A) a [genetic test](#d-17-A);
    - (B) genetic counseling (including obtaining, interpreting, or assessing [genetic information](#d-16-A)); or
    - (C) genetic education.
  - (19) **Underwriting purposes—** The term “underwriting purposes” means, with respect to any [group health plan](/usc/42/300bb–8.md?p=1), or [health insurance coverage](#b-1) offered in connection with a [group health plan](/usc/42/300bb–8.md?p=1)—
    - (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](/usc/42/300j–21.md?p=5) of a contract of health insurance or health benefits.
  - (20) **Qualified health plan—** The term “qualified health plan” has the meaning given such term in [section 18021(a) of this title](/usc/42/18021.md?p=a).
  - (21) **Exchange—** The term “Exchange” means an American Health Benefit Exchange established under [section 18031 of this title](/usc/42/18031.md).
- (e) **Definitions relating to markets and small employers—** For purposes of this subchapter:
  - (1) **Individual market—**
    - (A) **In general—** The term “individual market” means the market for [health insurance coverage](#b-1) offered to individuals other than in connection with a [group health plan](/usc/42/300bb–8.md?p=1).
    - (B) **Treatment of very small groups—**
      - (i) **In general—** Subject to [clause (ii)](#e-1-B-ii), such terms[^2] includes coverage offered in connection with a [group health plan](/usc/42/300bb–8.md?p=1) that has fewer than two [participants](#d-11) as current [employees](#d-5) on the first day of the plan year.
      - (ii) **State exception—** [Clause (i)](#e-1-B-i) shall not apply in the case of a [State](/usc/42/201.md?p=f) that elects to regulate the coverage described in such clause as coverage in the [small group market](#e-5).
  - (2) **Large employer—** The term “large employer” means, in connection with a [group health plan](/usc/42/300bb–8.md?p=1) with respect to a calendar year and a plan year, an [employer](#d-6) who employed an average of at least 51 [employees](#d-5) on business days during the preceding calendar year and who employs at least 2 [employees](#d-5) 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](#b-1) (directly or through any arrangement) on behalf of themselves (and their dependents) through a [group health plan](/usc/42/300bb–8.md?p=1) maintained by a [large employer](#e-2).
  - (4) **Small employer—** The term “small employer” means, in connection with a [group health plan](/usc/42/300bb–8.md?p=1) with respect to a calendar year and a plan year, an [employer](#d-6) who employed an average of at least 1 but not more than 50 [employees](#d-5) on business days during the preceding calendar year and who employs at least 1 [employees](#d-5)[^3] 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](#b-1) (directly or through any arrangement) on behalf of themselves (and their dependents) through a [group health plan](/usc/42/300bb–8.md?p=1) maintained by a [small employer](#e-4).
  - (6) **Application of certain rules in determination of employer size—** For purposes of this subsection—
    - (A) **Application of aggregation rule for employers—** all[^4] persons treated as a single [employer](#d-6) under subsection (b), (c), (m), or (o) of [section 414 of title 26](/usc/26/414.md) shall be treated as 1 [employer](#d-6).
    - (B) **Employers not in existence in preceding year—** In the case of an [employer](#d-6) which was not in existence throughout the preceding calendar year, the determination of whether such [employer](#d-6) is a small or [large employer](#e-2) shall be based on the average number of [employees](#d-5) that it is reasonably expected such [employer](#d-6) will employ on business days in the current calendar year.
    - (C) **Predecessors—** Any reference in this subsection to an [employer](#d-6) shall include a reference to any predecessor of such [employer](#d-6).
  - (7) **State option to extend definition of small employer—** Notwithstanding paragraphs [(2)](#e-2) and [(4)](#e-4), nothing in this section shall prevent a [State](/usc/42/201.md?p=f) from applying this subsection by treating as a [small employer](#e-4), with respect to a calendar year and a plan year, an [employer](#d-6) who employed an average of at least 1 but not more than 100 [employees](#d-5) on business days during the preceding calendar year and who employs at least 1 [employee](#d-5) on the first day of the plan year.

## Footnotes

[^1]: See References in Text note below.
[^2]: So in original. Probably should be “term”.
[^3]: So in original.
[^4]: So in original. Probably should be capitalized.

## Source credit

(July 1, 1944, ch. 373, title XXVII, § 2791, as added Pub. L. 104–191, title I, § 102(a), Aug. 21, 1996, 110 Stat. 1972; amended Pub. L. 110–233, title I, § 102(a)(4), May 21, 2008, 122 Stat. 890; Pub. L. 111–148, title I, § 1563(b), (c)(16), formerly § 1562(b), (c)(16), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 264, 269, 911; Pub. L. 114–60, § 2(b), Oct. 7, 2015, 129 Stat. 543; Pub. L. 114–255, div. C, title XVIII, § 18001(c)(1), Dec. 13, 2016, 130 Stat. 1344.)

## Notes

### Editorial Notes

### References in Text

The Social Security Act, referred to in subsec. (a)(1), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Part C of title XI of the Act is classified generally to part C (§ 1320d et seq.) of subchapter XI of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables.

Section 2701, referred to in subsecs. (a)(3) and (d)(15)(A), is a reference to section 2701 of act July 1, 1944. Section 2701, which was classified to section 300gg of this title, was renumbered section 2704, effective for plan years beginning on or after Jan. 1, 2014, with certain exceptions, and amended, by Pub. L. 111–148, title I, §§ 1201(2), 1563(c)(1), formerly § 1562(c)(1), title X, § 10107(b)(1), Mar. 23, 2010, 124 Stat. 154, 264, 911, and was transferred to section 300gg–3 of this title. A new section 2701 of act July 1, 1944, related to fair health insurance premiums, was added, effective for plan years beginning on or after Jan. 1, 2014, and amended, by Pub. L. 111–148, title I, § 1201(4), title X, § 10103(a), Mar. 23, 2010, 124 Stat. 155, 892, and is classified to section 300gg of this title.

The Employee Retirement Income Security Act of 1974, referred to in subsec. (d)(4)(B), is Pub. L. 93–406, Sept. 2, 1974, 88 Stat. 829. Part 6 of subtitle B of title I of the Act is classified generally to part 6 (§ 1161 et seq.) of subtitle B of subchapter I of chapter 18 of Title 29, Labor. For complete classification of this Act to the Code, see Short Title note set out under section 1001 of Title 29 and Tables.

Section 2702, referred to in subsec. (d)(9), is a reference to section 2702 of act July 1, 1944. Section 2702, which was classified to section 300gg–1 of this title, was amended by Pub. L. 111–148, title I, § 1201(3), Mar. 23, 2010, 124 Stat. 154, and was transferred to subsecs. (b) to (f) of section 300gg–4 of this title, effective for plan years beginning on or after Jan. 1, 2014. A new section 2702, related to guaranteed availability of coverage, was added by Pub. L. 111–148, title I, § 1201(4), Mar. 23, 2010, 124 Stat. 156, effective for plan years beginning on or after Jan. 1, 2014, and is classified to section 300gg–1 of this title.

### Amendments

2016—Subsec. (a)(1). Pub. L. 114–255 inserted at end “Except for purposes of part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.), such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26).”

2015—Subsec. (e)(2). Pub. L. 114–60, § 2(b)(1), substituted “51” for “101”.

Subsec. (e)(4). Pub. L. 114–60, § 2(b)(2), substituted “50” for “100”.

Subsec. (e)(7). Pub. L. 114–60, § 2(b)(3), added par. (7).

2010—Subsec. (d)(20), (21). Pub. L. 111–148, § 1563(b), formerly § 1562(b), as renumbered by Pub. L. 111–148, § 10107(b)(1), added pars. (20) and (21).

Subsec. (e)(2). Pub. L. 111–148, § 1563(c)(16)(A), formerly § 1562(c)(16)(A), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “101” for “51”.

Subsec. (e)(4). Pub. L. 111–148, § 1563(c)(16)(B), formerly § 1562(c)(16)(B), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “100” for “50” and “at least 1” for “at least 2” in two places.

2008—Subsec. (d)(15) to (19). Pub. L. 110–233 added pars. (15) to (19).

### 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(c)(3) of Pub. L. 114–255, set out as a note under section 300bb–8 of this title.

### Effective Date of 2008 Amendment

Amendment by Pub. L. 110–233 applicable, with respect to group health plans and health insurance coverage offered in connection with group health plans, for plan years beginning after the date that is one year after May 21, 2008, and, with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market, after the date that is one year after May 21, 2008, see section 102(d)(2) of Pub. L. 110–233, set out as a note under section 300gg–21 of this title.