54.9801-2—Definitions.
Unless otherwise provided, the definitions in this section govern in applying the provisions of § 54.9801-1, this section, §§ 54.9801-3 through 54.9801-6, 54.9802-1, 54.9802-2, 54.9802-3T, 54.9811-1, 54.9812-1T, 54.9831-1, and 54.9833-1.
Affiliation period means a period of time that must expire before health insurance coverage provided by an HMO becomes effective, and during which the HMO is not required to provide benefits.
COBRA definitions:
(2)
COBRA continuation coverage means coverage, under a group health plan, that satisfies an applicable COBRA continuation provision.
(3)
COBRA continuation provision means section 4980B (other than paragraph (f)(1) of section 4980B insofar as it relates to pediatric vaccines), sections 601-608 of ERISA, or Title XXII of the PHS Act.
(4)
Exhaustion of COBRA continuation coverage means that an individual's COBRA continuation coverage ceases for any reason other than either failure of the individual to pay premiums on a timely basis, or for cause (such as making a fraudulent claim or an intentional misrepresentation of a material fact in connection with the plan). An individual is considered to have exhausted COBRA continuation coverage if such coverage ceases—
(i)
Due to the failure of the employer or other responsible entity to remit premiums on a timely basis;
(ii)
When the individual no longer resides, lives, or works in the service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other COBRA continuation coverage available to the individual; or
(iii)
When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other COBRA continuation coverage available to the individual.
Condition means a medical condition.
Creditable coverage means creditable coverage within the meaning of § 54.9801-4(a).
Dependent means any individual who is or may become eligible for coverage under the terms of a group health plan because of a relationship to a participant.
Employee Retirement Income Security Act of 1974 (ERISA) means the Employee Retirement Income Security Act of 1974, as amended (29 U.S.C. 1001
et seq. ).
Enroll means to become covered for benefits under a group health plan (that is, when coverage becomes effective), without regard to when the individual may have completed or filed any forms that are required in order to become covered under the plan. For this purpose, an individual who has health coverage under a group health plan is enrolled in the plan regardless of whether the individual elects coverage, the individual is a dependent who becomes covered as a result of an election by a participant, or the individual becomes covered without an election.
Enrollment date definitions (enrollment date, first day of coverage, and waiting period) are set forth in § 54.9801-3(a)(3)(i), (ii), and (iii).
Excepted benefits means the benefits described as excepted in § 54.9831(c).
Genetic information has the meaning given the term in § 54.9802-3T(a)(3).
Group health insurance coverage means health insurance coverage offered in connection with a group health plan.
Group health plan or plan means a group health plan within the meaning of § 54.9831-1(a).
Group market means the market for health insurance coverage offered in connection with a group health plan. (However, certain very small plans may be treated as being in the individual market, rather than the group market; see the definition of individual market in this section.)
Health insurance coverage means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or HMO contract offered by a health insurance issuer. Health insurance coverage includes group health insurance coverage, individual health insurance coverage, and short-term, limited-duration insurance. However, benefits described in § 54.9831(c)(2) are not treated as benefits consisting of medical care.
Health insurance issuer or issuer means an insurance company, insurance service, or insurance organization (including an HMO) that is required to be licensed to engage in the business of insurance in a State and that is subject to State law that regulates insurance (within the meaning of section 514(b)(2) of ERISA). Such term does not include a group health plan.
Health maintenance organization or HMO means—
(1)
A federally qualified health maintenance organization (as defined in section 1301(a) of the PHS Act);
(3)
A similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization.
Individual health insurance coverage means health insurance coverage offered to individuals in the individual market, but does not include short-term, limited-duration insurance. Individual health insurance coverage can include dependent coverage.
Individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan. Unless a State elects otherwise in accordance with section 2791(e)(1)(B)(ii) of the PHS Act, such term also includes coverage offered in connection with a group health plan that has fewer than two participants who are current employees on the first day of the plan year.
Issuer means a health insurance issuer.
Late enrollment definitions (late enrollee and late enrollment) are set forth in § 54.9801-3(a)(3)(v) and (vi) .
Medical care has the meaning given such term by section 213(d), determined without regard to section 213(d)(1)(C) and so much of section 213(d)(1)(D) as relates to qualified long-term care insurance.
Medical condition or condition means any condition, whether physical or mental, including, but not limited to, any condition resulting from illness, injury (whether or not the injury is accidental), pregnancy, or congenital malformation. However, genetic information is not a condition.
Participant means participant within the meaning of section 3(7) of ERISA.
Placement, or being placed, for adoption means the assumption and retention of a legal obligation for total or partial support of a child by a person with whom the child has been placed in anticipation of the child's adoption. The child's placement for adoption with such person ends upon the termination of such legal obligation.
Plan year means the year that is designated as the plan year in the plan document of a group health plan, except that if the plan document does not designate a plan year or if there is no plan document, the plan year is—
(2)
If the plan does not impose deductibles or limits on a yearly basis, then the plan year is the policy year;
(3)
If the plan does not impose deductibles or limits on a yearly basis, and either the plan is not insured or the insurance policy is not renewed on an annual basis, then the plan year is the employer's taxable year; or
Preexisting condition exclusion means a limitation or exclusion of benefits (including a denial of coverage) based on the fact that the condition was present before the effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan or group or individual health insurance coverage (or other coverage provided to federally eligible individuals pursuant to 45 CFR part 148 ), whether or not any medical advice, diagnosis, care, or treatment was recommended or received before that day. A preexisting condition exclusion includes any limitation or exclusion of benefits (including a denial of coverage) applicable to an individual as a result of information relating to an individual's health status before the individual's effective date of coverage (or if coverage is denied, the date of the denial) under a group health plan, or group or individual health insurance coverage (or other coverage provided to Federally eligible individuals pursuant to 45 CFR part 148 ), such as a condition identified as a result of a pre-enrollment questionnaire or physical examination given to the individual, or review of medical records relating to the pre-enrollment period.
Public health plan means public health plan within the meaning of § 54.9801-4(a)(1)(ix).
Public Health Service Act (PHS Act) means the Public Health Service Act (42 U.S.C. 201, et seq. ).
Short-term, limited-duration insurance means health insurance coverage provided pursuant to a contract with an issuer that has an expiration date specified in the contract (taking into account any extensions that may be elected by the policyholder without the issuer's consent) that is less than 12 months after the original effective date of the contract.
Significant break in coverage means a significant break in coverage within the meaning of § 54.9801-4(b)(2)(iii).
Special enrollment means enrollment in a group health plan under the rights described in § 54.9801-6 or in group health insurance coverage under the rights described in 29 CFR 2590.701-6 or CFR 146.117.
State health benefits risk pool means a State health benefits risk pool within the meaning of § 54.9801-4(a)(1)(vii).
Waiting period means waiting period within the meaning of § 54.9801-3(a)(3)(iii).