USC Subchapter XX

USC Subchapter XX
in effect

42 U.S.C. § 300bb–1 State and local governmental group health plans must provide continuation coverage to certain individuals

(a) In generalIn accordance with regulations which the Secretary shall prescribe, each group health plan that is maintained by any State that receives funds under this chapter, by any political subdivision of such a State, or by any agency or instrumentality of such a State or political subdivision, shall provide, in accordance with this subchapter, that each qualified beneficiary who would lose coverage under the plan as a result of a qualifying event is entitled, under the plan, to elect, within the election period, continuation coverage under the plan. (b) Exception for certain plansSubsection (a) shall not apply to—(1) any group health plan for any calendar year if all employers maintaining such plan normally employed fewer than 20 employees on a typical business day during the preceding calendar year, or (2) any group health plan maintained for employees by the government of the District of Columbia or any territory or possession of the United States or any agency or instrumentality.

42 U.S.C. § 300bb–2 Continuation coverage

For purposes of section 300bb–1 of this title, the term “continuation coverage” means coverage under the plan which meets the following requirements: (1) Type of benefit coverageThe coverage must consist of coverage which, as of the time the coverage is being provided, is identical to the coverage provided under the plan to similarly situated beneficiaries under the plan with respect to whom a qualifying event has not occurred. If coverage is modified under the plan for any group of similarly situated beneficiaries, such coverage shall also be modified in the same manner for all individuals who are qualified beneficiaries under the plan pursuant to this part 11 So in original. This subchapter is not divided into parts. in connection with such group. (2) Period of coverageThe coverage must extend for at least the period beginning on the date of the qualifying event and ending not earlier than the earliest of the following:(A) Maximum required period(i) General rule for terminations and reduced hoursIn the case of a qualifying event described in section 300bb–3(2) of this title, except as provided in clause (ii), the date which is 18 months after the date of the qualifying event. (ii) Special rule for multiple qualifying eventsIf a qualifying event occurs during the 18 months after the date of a qualifying event described in section 300bb–3(2) of this title, the date which is 36 months after the date of the qualifying event described in section 300bb–3(2) of this title. (iii) General rule for other qualifying eventsIn the case of a qualifying event not described in section 300bb–3(2) of this title, the date which is 36 months after the date of the qualifying event. (iv) Special rule for TAA-eligible individualsIn the case of a qualifying event described in section 300bb–3(2) of this title with respect to a covered employee who is (as of the date that the period of coverage would, but for this clause or clause (v), otherwise terminate under clause (i) or (ii)) a TAA-eligible individual (as defined in section 300bb–5(b)(4)(B) of this title), the period of coverage shall not terminate by reason of clause (i) or (ii), as the case may be, before the later of the date specified in such clause or the date on which such individual ceases to be such a TAA-eligible individual. The preceding sentence shall not require any period of coverage to extend beyond January 1, 2014. (v) Medicare entitlement followed by qualifying eventIn the case of a qualifying event described in section 300bb–3(2) of this title that occurs less than 18 months after the date the covered employee became entitled to benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], the period of coverage for qualified beneficiaries other than the covered employee shall not terminate under this subparagraph before the close of the 36-month period beginning on the date the covered employee became so entitled. (vi) Special rule for disabilityIn the case of a qualified beneficiary who is determined, under title II or XVI of the Social Security Act [42 U.S.C. 401 et seq., 1381 et seq.], to have been disabled at any time during the first 60 days of continuation coverage under this subchapter, any reference in clause (i) or (ii) to 18 months is deemed a reference to 29 months (with respect to all qualified beneficiaries), but only if the qualified beneficiary has provided notice of such determination under section 300bb–6(3) of this title before the end of such 18 months. (B) End of planThe date on which the employer ceases to provide any group health plan to any employee. (C) Failure to pay premiumThe date on which coverage ceases under the plan by reason of a failure to make timely payment of any premium required under the plan with respect to the qualified beneficiary. The payment of any premium (other than any payment referred to in the last sentence of paragraph (3)) shall be considered to be timely if made within 30 days after the date due or within such longer period as applies to or under the plan. (D) Group health plan coverage or medicare entitlementThe date on which the qualified beneficiary first becomes, after the date of the election—(i) covered under any other group health plan (as an employee or otherwise) which does not contain any exclusion or limitation with respect to any preexisting condition of such beneficiary (other than such an exclusion or limitation which does not apply to (or is satisfied by) such beneficiary by reason of chapter 100 of title 26, part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1181 et seq.], or subchapter XXV of this chapter), or (ii) entitled to benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]. (E) Termination of extended coverage for disabilityIn the case of a qualified beneficiary who is disabled at any time during the first 60 days of continuation coverage under this subchapter, the month that begins more than 30 days after the date of the final determination under title II or XVI of the Social Security Act [42 U.S.C. 401 et seq., 1381 et seq.] that the qualified beneficiary is no longer disabled. (3) Premium requirementsThe plan may require payment of a premium for any period of continuation coverage, except that such premium—(A) shall not exceed 102 percent of the applicable premium for such period, and (B) may, at the election of the payor, be made in monthly installments. In no event may the plan require the payment of any premium before the day which is 45 days after the day on which the qualified beneficiary made the initial election for continuation coverage.22 See 1989 Amendment note below. In the case of an individual described in the last sentence of paragraph (2)(A), any reference in subparagraph (A) of this paragraph to “102 percent” is deemed a reference to “150 percent” for any month after the 18th month of continuation coverage described in clause (i) or (ii) of paragraph (2)(A). (4) No requirement of insurabilityThe coverage may not be conditioned upon, or discriminate on the basis of lack of, evidence of insurability. (5) Conversion optionIn the case of a qualified beneficiary whose period of continuation coverage expires under paragraph (2)(A), the plan must, during the 180-day period ending on such expiration date, provide to the qualified beneficiary the option of enrollment under a conversion health plan otherwise generally available under the plan.

42 U.S.C. § 300bb–3 Qualifying event

For purposes of this subchapter, the term “qualifying event” means, with respect to any covered employee, any of the following events which, but for the continuation coverage required under this subchapter, would result in the loss of coverage of a qualified beneficiary: (1) The death of the covered employee. (2) The termination (other than by reason of such employee’s gross misconduct), or reduction of hours, of the covered employee’s employment. (3) The divorce or legal separation of the covered employee from the employee’s spouse. (4) The covered employee becoming entitled to benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.]. (5) A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan.

42 U.S.C. § 300bb–4 Applicable premium

For purposes of this subchapter— (1) In generalThe term “applicable premium” means, with respect to any period of continuation coverage of qualified beneficiaries, the cost to the plan for such period of the coverage for similarly situated beneficiaries with respect to whom a qualifying event has not occurred (without regard to whether such cost is paid by the employer or employee). (2) Special rule for self-insured plansTo the extent that a plan is a self-insured plan—(A) In generalExcept as provided in subparagraph (B), the applicable premium for any period of continuation coverage of qualified beneficiaries shall be equal to a reasonable estimate of the cost of providing coverage for such period for similarly situated beneficiaries which—(i) is determined on an actuarial basis, and (ii) takes into account such factors as the Secretary may prescribe in regulations. (B) Determination on basis of past costIf a plan administrator elects to have this subparagraph apply, the applicable premium for any period of continuation coverage of qualified beneficiaries shall be equal to—(i) the cost to the plan for similarly situated beneficiaries for the same period occurring during the preceding determination period under paragraph (3), adjusted by (ii) the percentage increase or decrease in the implicit price deflator of the gross national product (calculated by the Department of Commerce and published in the Survey of Current Business) for the 12-month period ending on the last day of the sixth month of such preceding determination period. (C) Subparagraph (B) not to apply where significant changeA plan administrator may not elect to have subparagraph (B) apply in any case in which there is any significant difference, between the determination period and the preceding determination period, in coverage under, or in employees covered by, the plan. The determination under the preceding sentence for any determination period shall be made at the same time as the determination under paragraph (3). (3) Determination periodThe determination of any applicable premium shall be made for a period of 12 months and shall be made before the beginning of such period.

42 U.S.C. § 300bb–5 Election

(a) In generalFor purposes of this subchapter—(1) Election periodThe term “election period” means the period which—(A) begins not later than the date on which coverage terminates under the plan by reason of a qualifying event, (B) is of at least 60 days’ duration, and (C) ends not earlier than 60 days after the later of—(i) the date described in subparagraph (A), or (ii) in the case of any qualified beneficiary who receives notice under section 300bb–6(4) of this title, the date of such notice. (2) Effect of election on other beneficiariesExcept as otherwise specified in an election, any election of continuation coverage by a qualified beneficiary described in subparagraph (A)(i) or (B) of section 300bb–8(3) of this title shall be deemed to include an election of continuation coverage on behalf of any other qualified beneficiary who would lose coverage under the plan by reason of the qualifying event. If there is a choice among types of coverage under the plan, each qualified beneficiary is entitled to make a separate selection among such types of coverage. (b) Temporary extension of COBRA election period for certain individuals(1) In generalIn the case of a nonelecting TAA-eligible individual and notwithstanding subsection (a), such individual may elect continuation coverage under this subchapter during the 60-day period that begins on the first day of the month in which the individual becomes a TAA-eligible individual, but only if such election is made not later than 6 months after the date of the TAA-related loss of coverage. (2) Commencement of coverage; no reach-backAny continuation coverage elected by a TAA-eligible individual under paragraph (1) shall commence at the beginning of the 60-day election period described in such paragraph and shall not include any period prior to such 60-day election period. (3) Preexisting conditionsWith respect to an individual who elects continuation coverage pursuant to paragraph (1), the period—(A) beginning on the date of the TAA-related loss of coverage, and (B) ending on the first day of the 60-day election period described in paragraph (1), shall be disregarded for purposes of determining the 63-day periods referred to in section 2701(c)(2),11 See References in Text note below. section 1181(c)(2) of title 29, and section 9801(c)(2) of title 26. (4) DefinitionsFor purposes of this subsection:(A) Nonelecting TAA-eligible individualThe term “nonelecting TAA-eligible individual” means a TAA-eligible individual who—(i) has a TAA-related loss of coverage; and (ii) did not elect continuation coverage under this part 22 So in original. This subchapter is not divided into parts. during the TAA-related election period. (B) TAA-eligible individualThe term “TAA-eligible individual” means—(i) an eligible TAA recipient (as defined in paragraph (2) of section 35(c) of title 26), and (ii) an eligible alternative TAA recipient (as defined in paragraph (3) of such section). (C) TAA-related election periodThe term “TAA-related election period” means, with respect to a TAA-related loss of coverage, the 60-day election period under this part 2 which is a direct consequence of such loss. (D) TAA-related loss of coverageThe term “TAA-related loss of coverage” means, with respect to an individual whose separation from employment gives rise to being an TAA-eligible individual, the loss of health benefits coverage associated with such separation.

42 U.S.C. § 300bb–6 Notice requirements

In accordance with regulations prescribed by the Secretary— (1) the group health plan shall provide, at the time of commencement of coverage under the plan, written notice to each covered employee and spouse of the employee (if any) of the rights provided under this subsection,11 So in original. Probably should be “subchapter”. (2) the employer of an employee under a plan must notify the plan administrator of a qualifying event described in paragraph (1), (2), or (4) of section 300bb–3 of this title within 30 days of the date of the qualifying event, (3) each covered employee or qualified beneficiary is responsible for notifying the plan administrator of the occurrence of any qualifying event described in paragraph (3) or (5) of section 300bb–3 of this title within 60 days after the date of the qualifying event and each qualified beneficiary who is determined, under title II or XVI of the Social Security Act [42 U.S.C. 401 et seq., 1381 et seq.], to have been disabled at any time during the first 60 days of continuation coverage under this subchapter is responsible for notifying the plan administrator of such determination within 60 days after the date of the determination and for notifying the plan administrator within 30 days after the date of any final determination under such title or titles that the qualified beneficiary is no longer disabled, and (4) the plan administrator shall notify—(A) in the case of a qualifying event described in paragraph (1), (2), or (4) of section 300bb–3 of this title, any qualified beneficiary with respect to such event, and (B) in the case of a qualifying event described in paragraph (3) or (5) of section 300bb–3 of this title where the covered employee notifies the plan administrator under paragraph (3), any qualified beneficiary with respect to such event, of such beneficiary’s rights under this subsection.1 For purposes of paragraph (4), any notification shall be made within 14 days of the date on which the plan administrator is notified under paragraph (2) or (3), whichever is applicable, and any such notification to an individual who is a qualified beneficiary as the spouse of the covered employee shall be treated as notification to all other qualified beneficiaries residing with such spouse at the time such notification is made.

42 U.S.C. § 300bb–7 Enforcement

Any individual who is aggrieved by the failure of a State, political subdivision, or agency or instrumentality thereof, to comply with the requirements of this subchapter may bring an action for appropriate equitable relief.

42 U.S.C. § 300bb–8 Definitions

For purposes of this subchapter— (1) Group health planThe term “group health plan” has the meaning given such term in 5000(b) 11 So in original. Probably should be preceded by “section”. of title 26. Such term shall not include any plan substantially all of the coverage under which is for qualified long-term care services (as defined in section 7702B(c) of title 26). Such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26). (2) Covered employeeThe term “covered employee” means an individual who is (or was) provided coverage under a group health plan by virtue of the performance of services by the individual for 1 or more persons maintaining the plan (including as an employee defined in section 401(c)(1) of title 26). (3) Qualified beneficiary(A) In generalThe term “qualified beneficiary” means, with respect to a covered employee under a group health plan, any other individual who, on the day before the qualifying event for that employee, is a beneficiary under the plan—(i) as the spouse of the covered employee, or (ii) as the dependent child of the employee. Such term shall also include a child who is born to or placed for adoption with the covered employee during the period of continuation coverage under this subchapter. (B) Special rule for terminations and reduced employmentIn the case of a qualifying event described in section 300bb–3(2) of this title, the term “qualified beneficiary” includes the covered employee. (4) Plan administratorThe term “plan administrator” has the meaning given the term “administrator” by section 1002(16)(A) of title 29.

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