USC Subpart C

in effect

29 U.S.C. § 1191 Preemption; State flexibility; construction

(a) Continued applicability of State law with respect to health insurance issuers(1) In generalSubject to paragraph (2) and except as provided in subsection (b), this part shall not be construed to supersede any provision of State law which establishes, implements, or continues in effect any standard or requirement solely relating to health insurance issuers in connection with group health insurance coverage except to the extent that such standard or requirement prevents the application of a requirement of this part. (2) Continued preemption with respect to group health plansNothing in this part shall be construed to affect or modify the provisions of section 1144 of this title with respect to group health plans. (b) Special rules in case of portability requirements(1) In generalSubject to paragraph (2), the provisions of this part relating to health insurance coverage offered by a health insurance issuer supersede any provision of State law which establishes, implements, or continues in effect a standard or requirement applicable to imposition of a preexisting condition exclusion specifically governed by section 1181 of this title which differs from the standards or requirements specified in such section. (2) ExceptionsOnly in relation to health insurance coverage offered by a health insurance issuer, the provisions of this part do not supersede any provision of State law to the extent that such provision—(A) substitutes for the reference to “6-month period” in section 1181(a)(1) of this title a reference to any shorter period of time; (B) substitutes for the reference to “12 months” and “18 months” in section 1181(a)(2) of this title a reference to any shorter period of time; (C) substitutes for the references to “63 days” in sections 1181(c)(2)(A) and (d)(4)(A) 11 So in original. Section 1181(d)(4) of this title does not contain subpars. of this title a reference to any greater number of days; (D) substitutes for the reference to “30-day period” in sections 1181(b)(2) 22 So in original. Section 1181(b)(2) of this title does not refer to a 30-day period. and (d)(1) of this title a reference to any greater period; (E) prohibits the imposition of any preexisting condition exclusion in cases not described in section 1181(d) of this title or expands the exceptions described in such section; (F) requires special enrollment periods in addition to those required under section 1181(f) of this title; or (G) reduces the maximum period permitted in an affiliation period under section 1181(g)(1)(B) 33 So in original. Probably should be “1181(g)(1)(C)”. of this title. (c) Rules of constructionExcept as provided in section 1185 of this title, nothing in this part shall be construed as requiring a group health plan or health insurance coverage to provide specific benefits under the terms of such plan or coverage. (d) DefinitionsFor purposes of this section—(1) State lawThe term “State law” includes all laws, decisions, rules, regulations, or other State action having the effect of law, of any State. A law of the United States applicable only to the District of Columbia shall be treated as a State law rather than a law of the United States. (2) StateThe term “State” includes a State, the Northern Mariana Islands, any political subdivisions of a State or such Islands, or any agency or instrumentality of either.

29 U.S.C. § 1191a Special rules relating to group health plans

(a) General exception for certain small group health plansThe requirements of this part (other than sections 1185 and 1185o of this title) shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year if, on the first day of such plan year, such plan has less than 2 participants who are current employees. (b) Exception for certain benefitsThe requirements of this part shall not apply to any group health plan (and group health insurance coverage) in relation to its provision of excepted benefits described in section 1191b(c)(1) of this title. (c) Exception for certain benefits if certain conditions met(1) Limited, excepted benefitsThe requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) in relation to its provision of excepted benefits described in section 1191b(c)(2) of this title if the benefits—(A) are provided under a separate policy, certificate, or contract of insurance; or (B) are otherwise not an integral part of the plan. (2) Noncoordinated, excepted benefitsThe requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) in relation to its provision of excepted benefits described in section 1191b(c)(3) of this title if all of the following conditions are met:(A) The benefits are provided under a separate policy, certificate, or contract of insurance. (B) There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor. (C) Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor. (3) Supplemental excepted benefitsThe requirements of this part shall not apply to any group health plan (and group health insurance coverage) in relation to its provision of excepted benefits described in section 1191b(c)(4) of this title if the benefits are provided under a separate policy, certificate, or contract of insurance. (d) Treatment of partnershipsFor purposes of this part—(1) Treatment as a group health planAny plan, fund, or program which would not be (but for this subsection) an employee welfare benefit plan and which is established or maintained by a partnership, to the extent that such plan, fund, or program provides medical care (including items and services paid for as medical care) to present or former partners in the partnership or to their dependents (as defined under the terms of the plan, fund, or program), directly or through insurance, reimbursement, or otherwise, shall be treated (subject to paragraph (2)) as an employee welfare benefit plan which is a group health plan. (2) EmployerIn the case of a group health plan, the term “employer” also includes the partnership in relation to any partner. (3) Participants of group health plansIn the case of a group health plan, the term “participant” also includes—(A) in connection with a group health plan maintained by a partnership, an individual who is a partner in relation to the partnership, or (B) in connection with a group health plan maintained by a self-employed individual (under which one or more employees are participants), the self-employed individual, if such individual is, or may become, eligible to receive a benefit under the plan or such individual’s beneficiaries may be eligible to receive any such benefit.

29 U.S.C. § 1191b Definitions

(a) Group health planFor purposes of this part—(1) In generalThe 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 careThe 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 insuranceFor purposes of this part—(1) Health insurance coverageThe 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 issuerThe 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 organizationThe 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 coverageThe term “group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan. (c) Excepted benefitsFor 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 policyMedicare 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 definitionsFor purposes of this part—(1) COBRA continuation provisionThe 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 factorThe term “health status-related factor” means any of the factors described in section 1182(a)(1) of this title. (3) Network planThe 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 adoptionThe term “placement”, or being “placed”, for adoption, has the meaning given such term in section 1169(c)(3)(B) of this title. (5) Family memberThe 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 generalThe 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 researchSuch 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) ExclusionsThe term “genetic information” shall not include information about the sex or age of any individual. (7) Genetic test(A) In generalThe term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes. (B) ExceptionsThe 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 servicesThe term “genetic services” means—(A) a genetic test; (B) genetic counseling (including obtaining, interpreting, or assessing genetic information); or (C) genetic education. (9) Underwriting purposesThe 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.

29 U.S.C. § 1191c Regulations

The Secretary, consistent with section 104 of the Health Care Portability and Accountability Act of 1996, may promulgate such regulations as may be necessary or appropriate to carry out the provisions of this part. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this part.

29 U.S.C. § 1191d Standardized reporting format

(a) In generalNot later than 1 year after December 27, 2020, the Secretary shall establish (and periodically update) a standardized reporting format for the voluntary reporting, by group health plans to State All Payer Claims Databases, of medical claims, pharmacy claims, dental claims, and eligibility and provider files that are collected from private and public payers, and shall provide guidance to States on the process by which States may collect such data from such plans in the standardized reporting format. (b) Consultation(1) Advisory CommitteeNot later than 90 days after December 27, 2020, the Secretary shall convene an Advisory Committee (referred to in this section as the “Committee”), consisting of 15 members to advise the Secretary regarding the format and guidance described in paragraph (1).11 So in original. Probably should be “subsection (a).” (2) Membership(A) AppointmentIn accordance with subparagraph (B), not later than 90 days after December 27, 2020, the Secretary, in coordination with the Secretary of Health and Human Services, shall appoint under subparagraph (B)(iii), and the Comptroller General of the United States shall appoint under subparagraph (B)(iv), members who have distinguished themselves in the fields of health services research, health economics, health informatics, data privacy and security, or the governance of State All Payer Claims Databases, or who represent organizations likely to submit data to or use the database, including patients, employers, or employee organizations that sponsor group health plans, health care providers, health insurance issuers, or third-party administrators of group health plans. Such members shall serve 3-year terms on a staggered basis. Vacancies on the Committee shall be filled by appointment consistent with this paragraph not later than 3 months after the vacancy arises. (B) CompositionThe Committee shall be comprised of—(i) the Assistant Secretary of Employee Benefits and Security Administration of the Department of Labor, or a designee of such Assistant Secretary; (ii) the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services, or a designee of such Assistant Secretary; (iii) members appointed by the Secretary, in coordination with the Secretary of Health and Human Services, including—(I) 1 member to serve as the chair of the Committee; (II) 1 representative of the Centers for Medicare & Medicaid Services; (III) 1 representative of the Agency for Healthcare Research and Quality; (IV) 1 representative of the Office for Civil Rights of the Department of Health and Human Services with expertise in data privacy and security; (V) 1 representative of the National Center for Health Statistics; (VI) 1 representative of the Office of the National Coordinator for Health Information Technology; and (VII) 1 representative of a State All-Payer 22 So in original. Definition in subsec. (c) does not contain hyphen in “All Payer”. Claims Database; (iv) members appointed by the Comptroller General of the United States, including—(I) 1 representative of an employer that sponsors a group health plan; (II) 1 representative of an employee organization that sponsors a group health plan; (III) 1 academic researcher with expertise in health economics or health services research; (IV) 1 consumer advocate; and (V) 2 additional members. (3) ReportNot later than 180 days after December 27, 2020, the Committee shall report to the Secretary, the Committee on Health, Education, Labor, and Pensions of the Senate, and the Committee on Energy and Commerce and the Committee on Education and Labor of the House of Representatives. Such report shall include recommendations on the establishment of the format and guidance described in subsection (a). (c) State All Payer Claims DatabaseIn this section, the term “State All Payer Claims Database” means, with respect to a State, a database that may include medical claims, pharmacy claims, dental claims, and eligibility and provider files, which are collected from private and public payers. (d) Authorization of appropriationsTo carry out this section, there are authorized to be appropriated $5,000,000 for fiscal year 2021, to remain available until expended or, if sooner, until the date described in subsection (e). (e) SunsetBeginning on the date on which the report is submitted under subsection (b)(3), subsection (b) shall have no force or effect.