§ 300gg-91. Definitions
(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 [29 U.S.C. 1002
(1)]) 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)
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 [29 U.S.C. 1144
(b)(2)]). Such term does not include a group health plan.
(3)
Health maintenance organization
The term “health maintenance organization” means—
(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:
(2)
Benefits not subject to requirements if offered separately
(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 subchapter for the State involved with respect to such issuer.
(3)
Bona fide association
The term “bona fide association” means, with respect to health insurance coverage offered in a State, an association which—
(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);
(4)
COBRA continuation provision
The term “COBRA continuation provision” means any of the following:
(A)
Section
4980B of title
26, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.
(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 [29 U.S.C. 1002
(32)] and any Federal governmental plan.
(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.
(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.
(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.
(15)
Family member
The term “family member” means, with respect to any individual—
(16)
Genetic information
(A)
In general
The term “genetic information” means, with respect to any individual, information about—
(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.
(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.
(19)
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—
(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 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 [1] 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.
(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—
(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.
[1] So in original. Probably should be “term”.
[2] So in original. Probably should be capitalized.