-CITE-
26 USC CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
-HEAD-
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
-MISC1-
Subchapter Sec.(!1)
A. Requirements relating to portability, access, and
renewability 9801
B. Other requirements 9811
C. General provisions 9831
AMENDMENTS
1997 - Pub. L. 105-34, title XV, Sec. 1531(a)(1), Aug. 5, 1997,
111 Stat. 1080, struck out "PORTABILITY, ACCESS, AND RENEWABILITY"
in chapter heading and added analysis for chapter.
-SECREF-
CHAPTER REFERRED TO IN OTHER SECTIONS
This chapter is referred to in sections 4980B, 4980D of this
title; title 29 section 1162; title 42 section 300bb-2.
-FOOTNOTE-
(!1) Section numbers editorially supplied.
-End-
-CITE-
26 USC Subchapter A - Requirements Relating to
Portability, Access, and Renewability 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
SUBCHAPTER A - REQUIREMENTS RELATING TO PORTABILITY, ACCESS, AND
RENEWABILITY
-MISC1-
Sec.
9801. Increased portability through limitation on
preexisting condition exclusions.
9802. Prohibiting discrimination against individual
participants and beneficiaries based on health
status.
9803. Guaranteed renewability in multiemployer plans and
certain multiple employer welfare arrangements.
AMENDMENTS
1997 - Pub. L. 105-34, title XV, Sec. 1531(a)(1), Aug. 5, 1997,
111 Stat. 1081, added subchapter heading and items 9801 to 9803 and
struck out former items 9801 "Increased portability through
limitation on preexisting condition exclusions", 9802 "Prohibiting
discrimination against individual participants and beneficiaries
based on health status", 9803 "Guaranteed renewability in
multiemployer plans and certain multiple employer welfare
arrangements", 9804 "General exceptions", 9805 "Definitions", and
9806 "Regulations".
-End-
-CITE-
26 USC Sec. 9801 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
Sec. 9801. Increased portability through limitation on preexisting
condition exclusions
-STATUTE-
(a) Limitation on preexisting condition exclusion period; crediting
for periods of previous coverage
Subject to subsection (d), a group health plan may, with respect
to a participant or beneficiary, impose a preexisting condition
exclusion only if -
(1) such exclusion relates to a condition (whether physical or
mental), regardless of the cause of the condition, for which
medical advice, diagnosis, care, or treatment was recommended or
received within the 6-month period ending on the enrollment date;
(2) such exclusion extends for a period of not more than 12
months (or 18 months in the case of a late enrollee) after the
enrollment date; and
(3) the period of any such preexisting condition exclusion is
reduced by the length of the aggregate of the periods of
creditable coverage (if any) applicable to the participant or
beneficiary as of the enrollment date.
(b) Definitions
For purposes of this section -
(1) Preexisting condition exclusion
(A) In general
The term "preexisting condition exclusion" means, with
respect to coverage, a limitation or exclusion of benefits
relating to a condition based on the fact that the condition
was present before the date of enrollment for such coverage,
whether or not any medical advice, diagnosis, care, or
treatment was recommended or received before such date.
(B) Treatment of genetic information
For purposes of this section, genetic information shall not
be treated as a condition described in subsection (a)(1) in the
absence of a diagnosis of the condition related to such
information.
(2) Enrollment date
The term "enrollment date" means, with respect to an individual
covered under a group health plan, the date of enrollment of the
individual in the plan or, if earlier, the first day of the
waiting period for such enrollment.
(3) Late enrollee
The term "late enrollee" means, with respect to coverage under
a group health plan, a participant or beneficiary who enrolls
under the plan other than during -
(A) the first period in which the individual is eligible to
enroll under the plan, or
(B) a special enrollment period under subsection (f).
(4) Waiting period
The term "waiting period" means, with respect to a group health
plan and an individual who is a potential participant or
beneficiary in the plan, the period that must pass with respect
to the individual before the individual is eligible to be covered
for benefits under the terms of the plan.
(c) Rules relating to crediting previous coverage
(1) Creditable coverage defined
For purposes of this part, the term "creditable coverage"
means, with respect to an individual, coverage of the individual
under any of the following:
(A) A group health plan.
(B) Health insurance coverage.
(C) Part A or part B of title XVIII of the Social Security
Act.
(D) Title XIX of the Social Security Act, other than coverage
consisting solely of benefits under section 1928.
(E) Chapter 55 of title 10, United States Code.
(F) A medical care program of the Indian Health Service or of
a tribal organization.
(G) A State health benefits risk pool.
(H) A health plan offered under chapter 89 of title 5, United
States Code.
(I) A public health plan (as defined in regulations).
(J) A health benefit plan under section 5(e) of the Peace
Corps Act (22 U.S.C. 2504(e)).
Such term does not include coverage consisting solely of coverage
of excepted benefits (as defined in section 9832(c)).
(2) Not counting periods before significant breaks in coverage
(A) In general
A period of creditable coverage shall not be counted, with
respect to enrollment of an individual under a group health
plan, if, after such period and before the enrollment date,
there was a 63-day period during all of which the individual
was not covered under any creditable coverage.
(B) Waiting period not treated as a break in coverage
For purposes of subparagraph (A) and subsection (d)(4), any
period that an individual is in a waiting period for any
coverage under a group health plan or is in an affiliation
period shall not be taken into account in determining the
continuous period under subparagraph (A).
(C) Affiliation period
(i) In general
For purposes of this section, the term "affiliation period"
means a period which, under the terms of the health insurance
coverage offered by the health maintenance organization, must
expire before the health insurance coverage becomes
effective. During such an affiliation period, the
organization is not required to provide health care services
or benefits and no premium shall be charged to the
participant or beneficiary.
(ii) Beginning
Such period shall begin on the enrollment date.
(iii) Runs concurrently with waiting periods
Any such affiliation period shall run concurrently with any
waiting period under the plan.
(3) Method of crediting coverage
(A) Standard method
Except as otherwise provided under subparagraph (B), for
purposes of applying subsection (a)(3), a group health plan
shall count a period of creditable coverage without regard to
the specific benefits for which coverage is offered during the
period.
(B) Election of alternative method
A group health plan may elect to apply subsection (a)(3)
based on coverage of any benefits within each of several
classes or categories of benefits specified in regulations
rather than as provided under subparagraph (A). Such election
shall be made on a uniform basis for all participants and
beneficiaries. Under such election a group health plan shall
count a period of creditable coverage with respect to any class
or category of benefits if any level of benefits is covered
within such class or category.
(C) Plan notice
In the case of an election with respect to a group health
plan under subparagraph (B), the plan shall -
(i) prominently state in any disclosure statements
concerning the plan, and state to each enrollee at the time
of enrollment under the plan, that the plan has made such
election, and
(ii) include in such statements a description of the effect
of this election.
(4) Establishment of period
Periods of creditable coverage with respect to an individual
shall be established through presentation of certifications
described in subsection (e) or in such other manner as may be
specified in regulations.
(d) Exceptions
(1) Exclusion not applicable to certain newborns
Subject to paragraph (4), a group health plan may not impose
any preexisting condition exclusion in the case of an individual
who, as of the last day of the 30-day period beginning with the
date of birth, is covered under creditable coverage.
(2) Exclusion not applicable to certain adopted children
Subject to paragraph (4), a group health plan may not impose
any preexisting condition exclusion in the case of a child who is
adopted or placed for adoption before attaining 18 years of age
and who, as of the last day of the 30-day period beginning on the
date of the adoption or placement for adoption, is covered under
creditable coverage. The previous sentence shall not apply to
coverage before the date of such adoption or placement for
adoption.
(3) Exclusion not applicable to pregnancy
For purposes of this section, a group health plan may not
impose any preexisting condition exclusion relating to pregnancy
as a preexisting condition.
(4) Loss if break in coverage
Paragraphs (1) and (2) shall no longer apply to an individual
after the end of the first 63-day period during all of which the
individual was not covered under any creditable coverage.
(e) Certifications and disclosure of coverage
(1) Requirement for certification of period of creditable
coverage
(A) In general
A group health plan shall provide the certification described
in subparagraph (B) -
(i) at the time an individual ceases to be covered under
the plan or otherwise becomes covered under a COBRA
continuation provision,
(ii) in the case of an individual becoming covered under
such a provision, at the time the individual ceases to be
covered under such provision, and
(iii) on the request on behalf of an individual made not
later than 24 months after the date of cessation of the
coverage described in clause (i) or (ii), whichever is later.
The certification under clause (i) may be provided, to the
extent practicable, at a time consistent with notices required
under any applicable COBRA continuation provision.
(B) Certification
The certification described in this subparagraph is a written
certification of -
(i) the period of creditable coverage of the individual
under such plan and the coverage under such COBRA
continuation provision, and
(ii) the waiting period (if any) (and affiliation period,
if applicable) imposed with respect to the individual for any
coverage under such plan.
(C) Issuer compliance
To the extent that medical care under a group health plan
consists of health insurance coverage offered in connection
with the plan, the plan is deemed to have satisfied the
certification requirement under this paragraph if the issuer
provides for such certification in accordance with this
paragraph.
(2) Disclosure of information on previous benefits
(A) In general
In the case of an election described in subsection (c)(3)(B)
by a group health plan, if the plan enrolls an individual for
coverage under the plan and the individual provides a
certification of coverage of the individual under paragraph (1)
-
(i) upon request of such plan, the entity which issued the
certification provided by the individual shall promptly
disclose to such requesting plan information on coverage of
classes and categories of health benefits available under
such entity's plan, and
(ii) such entity may charge the requesting plan or issuer
for the reasonable cost of disclosing such information.
(3) Regulations
The Secretary shall establish rules to prevent an entity's
failure to provide information under paragraph (1) or (2) with
respect to previous coverage of an individual from adversely
affecting any subsequent coverage of the individual under another
group health plan or health insurance coverage.
(f) Special enrollment periods
(1) Individuals losing other coverage
A group health plan shall permit an employee who is eligible,
but not enrolled, for coverage under the terms of the plan (or a
dependent of such an employee if the dependent is eligible, but
not enrolled, for coverage under such terms) to enroll for
coverage under the terms of the plan if each of the following
conditions is met:
(A) The employee or dependent was covered under a group
health plan or had health insurance coverage at the time
coverage was previously offered to the employee or individual.
(B) The employee stated in writing at such time that coverage
under a group health plan or health insurance coverage was the
reason for declining enrollment, but only if the plan sponsor
(or the health insurance issuer offering health insurance
coverage in connection with the plan) required such a statement
at such time and provided the employee with notice of such
requirement (and the consequences of such requirement) at such
time.
(C) The employee's or dependent's coverage described in
subparagraph (A) -
(i) was under a COBRA continuation provision and the
coverage under such provision was exhausted; or
(ii) was not under such a provision and either the coverage
was terminated as a result of loss of eligibility for the
coverage (including as a result of legal separation, divorce,
death, termination of employment, or reduction in the number
of hours of employment) or employer contributions toward such
coverage were terminated.
(D) Under the terms of the plan, the employee requests such
enrollment not later than 30 days after the date of exhaustion
of coverage described in subparagraph (C)(i) or termination of
coverage or employer contribution described in subparagraph
(C)(ii).
(2) For dependent beneficiaries
(A) In general
If -
(i) a group health plan makes coverage available with
respect to a dependent of an individual,
(ii) the individual is a participant under the plan (or has
met any waiting period applicable to becoming a participant
under the plan and is eligible to be enrolled under the plan
but for a failure to enroll during a previous enrollment
period), and
(iii) a person becomes such a dependent of the individual
through marriage, birth, or adoption or placement for
adoption,
the group health plan shall provide for a dependent special
enrollment period described in subparagraph (B) during which
the person (or, if not otherwise enrolled, the individual) may
be enrolled under the plan as a dependent of the individual,
and in the case of the birth or adoption of a child, the spouse
of the individual may be enrolled as a dependent of the
individual if such spouse is otherwise eligible for coverage.
(B) Dependent special enrollment period
The dependent special enrollment period under this
subparagraph shall be a period of not less than 30 days and
shall begin on the later of -
(i) the date dependent coverage is made available, or
(ii) the date of the marriage, birth, or adoption or
placement for adoption (as the case may be) described in
subparagraph (A)(iii).
(C) No waiting period
If an individual seeks coverage of a dependent during the
first 30 days of such a dependent special enrollment period,
the coverage of the dependent shall become effective -
(i) in the case of marriage, not later than the first day
of the first month beginning after the date the completed
request for enrollment is received;
(ii) in the case of a dependent's birth, as of the date of
such birth; or
(iii) in the case of a dependent's adoption or placement
for adoption, the date of such adoption or placement for
adoption.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2073; amended Pub. L. 105-34, title XV, Sec. 1531(b)(1)(A),
Aug. 5, 1997, 111 Stat. 1084.)
-REFTEXT-
REFERENCES IN TEXT
The Social Security Act, referred to in subsec. (c)(1)(C), (D),
is act Aug. 14, 1935, ch. 531, 49 Stat. 620, as amended. Parts A
and B of title XVIII of the Act are classified generally to parts A
(Sec. 1395c et seq.) and B (Sec. 1395j et seq.) of subchapter XVIII
of chapter 7 of Title 42, The Public Health and Welfare. Title XIX
of the Act is classified generally to subchapter XIX (Sec. 1396 et
seq.) of chapter 7 of Title 42. Section 1928 of the Act is
classified to section 1396s of Title 42. For complete
classification of this Act to the Code, see section 1305 of Title
42 and Tables.
-MISC1-
AMENDMENTS
1997 - Subsec. (c)(1). Pub. L. 105-34 substituted "section
9832(c)" for "section 9805(c)" in concluding provisions.
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105-34 applicable with respect to group
health plans for plan years beginning on or after Jan. 1, 1998, see
section 1531(c) of Pub. L. 105-34, set out as a note under section
4980D of this title.
EFFECTIVE DATE
Section 401(c) of Pub. L. 104-191 provided that:
"(1) In general. - The amendments made by this section [enacting
this subtitle] shall apply to plan years beginning after June 30,
1997.
"(2) Determination of creditable coverage. -
"(A) Period of coverage. -
"(i) In general. - Subject to clause (ii), no period before
July 1, 1996, shall be taken into account under chapter 100 of
the Internal Revenue Code of 1986 (as added by this section) in
determining creditable coverage.
"(ii) Special rule for certain periods. - The Secretary of
the Treasury, consistent with section 104 [42 U.S.C. 300gg-92
note], shall provide for a process whereby individuals who need
to establish creditable coverage for periods before July 1,
1996, and who would have such coverage credited but for clause
(i) may be given credit for creditable coverage for such
periods through the presentation of documents or other means.
"(B) Certifications, etc. -
"(i) In general. - Subject to clauses (ii) and (iii),
subsection (e) of section 9801 of the Internal Revenue Code of
1986 (as added by this section) shall apply to events occurring
after June 30, 1996.
"(ii) No certification required to be provided before june 1,
1997. - In no case is a certification required to be provided
under such subsection before June 1, 1997.
"(iii) Certification only on written request for events
occurring before october 1, 1996. - In the case of an event
occurring after June 30, 1996, and before October 1, 1996, a
certification is not required to be provided under such
subsection unless an individual (with respect to whom the
certification is otherwise required to be made) requests such
certification in writing.
"(C) Transitional rule. - In the case of an individual who
seeks to establish creditable coverage for any period for which
certification is not required because it relates to an event
occurring before June 30, 1996 -
"(i) the individual may present other credible evidence of
such coverage in order to establish the period of creditable
coverage; and
"(ii) a group health plan and a health insurance issuer shall
not be subject to any penalty or enforcement action with
respect to the plan's or issuer's crediting (or not crediting)
such coverage if the plan or issuer has sought to comply in
good faith with the applicable requirements under the
amendments made by this section.
"(3) Special rule for collective bargaining agreements. - Except
as provided in paragraph (2), in the case of a group health plan
maintained pursuant to 1 or more collective bargaining agreements
between employee representatives and one or more employers ratified
before the date of the enactment of this Act [Aug. 21, 1996], the
amendments made by this section shall not apply to plan years
beginning before the later of -
"(A) the date on which the last of the collective bargaining
agreements relating to the plan terminates (determined without
regard to any extension thereof agreed to after the date of the
enactment of this Act), or
"(B) July 1, 1997.
For purposes of subparagraph (A), any plan amendment made pursuant
to a collective bargaining agreement relating to the plan which
amends the plan solely to conform to any requirement added by this
section shall not be treated as a termination of such collective
bargaining agreement.
"(4) Timely regulations. - The Secretary of the Treasury,
consistent with section 104, shall first issue by not later than
April 1, 1997, such regulations as may be necessary to carry out
the amendments made by this section.
"(5) Limitation on actions. - No enforcement action shall be
taken, pursuant to the amendments made by this section, against a
group health plan or health insurance issuer with respect to a
violation of a requirement imposed by such amendments before
January 1, 1998, or, if later, the date of issuance of regulations
referred to in paragraph (4), if the plan or issuer has sought to
comply in good faith with such requirements."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 35, 4980B, 9802 of this
title; title 29 sections 1165, 2918; title 42 section 300bb-5.
-End-
-CITE-
26 USC Sec. 9802 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
Sec. 9802. Prohibiting discrimination against individual
participants and beneficiaries based on health status
-STATUTE-
(a) In eligibility to enroll
(1) In general
Subject to paragraph (2), a group health plan may not establish
rules for eligibility (including continued eligibility) of any
individual to enroll under the terms of the plan based on any of
the following factors in relation to the individual or a
dependent of the individual:
(A) Health status.
(B) Medical condition (including both physical and mental
illnesses).
(C) Claims experience.
(D) Receipt of health care.
(E) Medical history.
(F) Genetic information.
(G) Evidence of insurability (including conditions arising
out of acts of domestic violence).
(H) Disability.
(2) No application to benefits or exclusions
To the extent consistent with section 9801, paragraph (1) shall
not be construed -
(A) to require a group health plan to provide particular
benefits (or benefits with respect to a specific procedure,
treatment, or service) other than those provided under the
terms of such plan; or
(B) to prevent such a plan from establishing limitations or
restrictions on the amount, level, extent, or nature of the
benefits or coverage for similarly situated individuals
enrolled in the plan or coverage.
(3) Construction
For purposes of paragraph (1), rules for eligibility to enroll
under a plan include rules defining any applicable waiting
periods for such enrollment.
(b) In premium contributions
(1) In general
A group health plan may not require any individual (as a
condition of enrollment or continued enrollment under the plan)
to pay a premium or contribution which is greater than such
premium or contribution for a similarly situated individual
enrolled in the plan on the basis of any factor described in
subsection (a)(1) in relation to the individual or to an
individual enrolled under the plan as a dependent of the
individual.
(2) Construction
Nothing in paragraph (1) shall be construed -
(A) to restrict the amount that an employer may be charged
for coverage under a group health plan; or
(B) to prevent a group health plan from establishing premium
discounts or rebates or modifying otherwise applicable
copayments or deductibles in return for adherence to programs
of health promotion and disease prevention.
(c) Special rules for church plans
A church plan (as defined in section 414(e)) shall not be treated
as failing to meet the requirements of this section solely because
such plan requires evidence of good health for coverage of -
(1) both any employee of an employer with 10 or less employees
(determined without regard to section 414(e)(3)(C)) and any
self-employed individual, or
(2) any individual who enrolls after the first 90 days of
initial eligibility under the plan.
This subsection shall apply to a plan for any year only if the plan
included the provisions described in the preceding sentence on July
15, 1997, and at all times thereafter before the beginning of such
year.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2078; amended Pub. L. 105-34, title XV, Sec. 1532(a), Aug. 5,
1997, 111 Stat. 1085.)
-MISC1-
AMENDMENTS
1997 - Subsec. (c). Pub. L. 105-34 added subsec. (c).
EFFECTIVE DATE OF 1997 AMENDMENT
Section 1532(b) of Pub. L. 105-34 provided that: "The amendments
made by subsection (a) [amending this section] shall take effect as
if included in the amendments made by section 401(a) of the Health
Insurance Portability and Accountability Act of 1996 [Pub. L.
104-191]."
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 9803 of this title.
-End-
-CITE-
26 USC Sec. 9803 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
Sec. 9803. Guaranteed renewability in multiemployer plans and
certain multiple employer welfare arrangements
-STATUTE-
(a) In general
A group health plan which is a multiemployer plan (as defined in
section 414(f)) or which is a multiple employer welfare arrangement
may not deny an employer continued access to the same or different
coverage under such plan, other than -
(1) for nonpayment of contributions;
(2) for fraud or other intentional misrepresentation of
material fact by the employer;
(3) for noncompliance with material plan provisions;
(4) because the plan is ceasing to offer any coverage in a
geographic area;
(5) in the case of a plan that offers benefits through a
network plan, because there is no longer any individual enrolled
through the employer who lives, resides, or works in the service
area of the network plan and the plan applies this paragraph
uniformly without regard to the claims experience of employers or
a factor described in section 9802(a)(1) in relation to such
individuals or their dependents; or
(6) for failure to meet the terms of an applicable collective
bargaining agreement, to renew a collective bargaining or other
agreement requiring or authorizing contributions to the plan, or
to employ employees covered by such an agreement.
(b) Multiple employer welfare arrangement
For purposes of subsection (a), the term "multiple employer
welfare arrangement" has the meaning given such term by section
3(40) of the Employee Retirement Income Security Act of 1974, as in
effect on the date of the enactment of this section.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2079.)
-REFTEXT-
REFERENCES IN TEXT
Section 3(40) of the Employee Retirement Income Security Act of
1974, referred to in subsec. (b), is classified to section 1002(40)
of Title 29, Labor.
The date of the enactment of this section, referred to in subsec.
(b), is the date of enactment of Pub. L. 104-191, which was
approved Aug. 21, 1996.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 4980D of this title.
-End-
-CITE-
26 USC Sec. 9804 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
[Sec. 9804. Renumbered Sec. 9831]
-STATUTE-
-End-
-CITE-
26 USC Sec. 9805 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
[Sec. 9805. Renumbered Sec. 9832]
-STATUTE-
-End-
-CITE-
26 USC Sec. 9806 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter A - Requirements Relating to Portability, Access, and
Renewability
-HEAD-
[Sec. 9806. Renumbered Sec. 9833]
-STATUTE-
-End-
-CITE-
26 USC Subchapter B - Other Requirements 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter B - Other Requirements
-HEAD-
SUBCHAPTER B - OTHER REQUIREMENTS
-MISC1-
Sec.
9811. Standards relating to benefits for mothers and
newborns.
9812. Parity in the application of certain limits to mental
health benefits.
AMENDMENTS
1997 - Pub. L. 105-34, title XV, Sec. 1531(a)(4), Aug. 5, 1997,
111 Stat. 1081, added subchapter heading and analysis.
-End-
-CITE-
26 USC Sec. 9811 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter B - Other Requirements
-HEAD-
Sec. 9811. Standards relating to benefits for mothers and newborns
-STATUTE-
(a) Requirements for minimum hospital stay following birth
(1) In general
A group health plan may not -
(A) except as provided in paragraph (2) -
(i) restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child,
following a normal vaginal delivery, to less than 48 hours,
or
(ii) restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child,
following a caesarean section, to less than 96 hours; or
(B) require that a provider obtain authorization from the
plan or the issuer for prescribing any length of stay required
under subparagraph (A) (without regard to paragraph (2)).
(2) Exception
Paragraph (1)(A) shall not apply in connection with any group
health plan in any case in which the decision to discharge the
mother or her newborn child prior to the expiration of the
minimum length of stay otherwise required under paragraph (1)(A)
is made by an attending provider in consultation with the mother.
(b) Prohibitions
A group health plan may not -
(1) deny to the mother or her newborn child eligibility, or
continued eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding the
requirements of this section;
(2) provide monetary payments or rebates to mothers to
encourage such mothers to accept less than the minimum
protections available under this section;
(3) penalize or otherwise reduce or limit the reimbursement of
an attending provider because such provider provided care to an
individual participant or beneficiary in accordance with this
section;
(4) provide incentives (monetary or otherwise) to an attending
provider to induce such provider to provide care to an individual
participant or beneficiary in a manner inconsistent with this
section; or
(5) subject to subsection (c)(3), restrict benefits for any
portion of a period within a hospital length of stay required
under subsection (a) in a manner which is less favorable than the
benefits provided for any preceding portion of such stay.
(c) Rules of construction
(1) Nothing in this section shall be construed to require a
mother who is a participant or beneficiary -
(A) to give birth in a hospital; or
(B) to stay in the hospital for a fixed period of time
following the birth of her child.
(2) This section shall not apply with respect to any group health
plan which does not provide benefits for hospital lengths of stay
in connection with childbirth for a mother or her newborn child.
(3) Nothing in this section shall be construed as preventing a
group health plan from imposing deductibles, coinsurance, or other
cost-sharing in relation to benefits for hospital lengths of stay
in connection with childbirth for a mother or newborn child under
the plan, except that such coinsurance or other cost-sharing for
any portion of a period within a hospital length of stay required
under subsection (a) may not be greater than such coinsurance or
cost-sharing for any preceding portion of such stay.
(d) Level and type of reimbursements
Nothing in this section shall be construed to prevent a group
health plan from negotiating the level and type of reimbursement
with a provider for care provided in accordance with this section.
(e) Preemption; exception for health insurance coverage in certain
States
The requirements of this section shall not apply with respect to
health insurance coverage if there is a State law (including a
decision, rule, regulation, or other State action having the effect
of law) for a State that regulates such coverage that is described
in any of the following paragraphs:
(1) Such State law requires such coverage to provide for at
least a 48-hour hospital length of stay following a normal
vaginal delivery and at least a 96-hour hospital length of stay
following a caesarean section.
(2) Such State law requires such coverage to provide for
maternity and pediatric care in accordance with guidelines
established by the American College of Obstetricians and
Gynecologists, the American Academy of Pediatrics, or other
established professional medical associations.
(3) Such State law requires, in connection with such coverage
for maternity care, that the hospital length of stay for such
care is left to the decision of (or required to be made by) the
attending provider in consultation with the mother.
-SOURCE-
(Added Pub. L. 105-34, title XV, Sec. 1531(a)(4), Aug. 5, 1997, 111
Stat. 1081; amended Pub. L. 105-206, title VI, Sec. 6015(e), July
22, 1998, 112 Stat. 821.)
-MISC1-
AMENDMENTS
1998 - Subsecs. (e), (f). Pub. L. 105-206 redesignated subsec.
(f) as (e).
EFFECTIVE DATE OF 1998 AMENDMENT
Amendment by Pub. L. 105-206 effective, except as otherwise
provided, as if included in the provisions of the Taxpayer Relief
Act of 1997, Pub. L. 105-34, to which such amendment relates, see
section 6024 of Pub. L. 105-206, set out as a note under section 1
of this title.
EFFECTIVE DATE
Subchapter applicable with respect to group health plans for plan
years beginning on or after Jan. 1, 1998, see section 1531(c) of
Pub. L. 105-34, set out as an Effective Date of 1997 Amendment note
under section 4980D of this title.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in section 4980D of this title.
-End-
-CITE-
26 USC Sec. 9812 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter B - Other Requirements
-HEAD-
Sec. 9812. Parity in the application of certain limits to mental
health benefits
-STATUTE-
(a) In general
(1) Aggregate lifetime limits
In the case of a group health plan that provides both medical
and surgical benefits and mental health benefits -
(A) No lifetime limit
If the plan does not include an aggregate lifetime limit on
substantially all medical and surgical benefits, the plan may
not impose any aggregate lifetime limit on mental health
benefits.
(B) Lifetime limit
If the plan includes an aggregate lifetime limit on
substantially all medical and surgical benefits (in this
paragraph referred to as the "applicable lifetime limit"), the
plan shall either -
(i) apply the applicable lifetime limit both to the medical
and surgical benefits to which it otherwise would apply and
to mental health benefits and not distinguish in the
application of such limit between such medical and surgical
benefits and mental health benefits; or
(ii) not include any aggregate lifetime limit on mental
health benefits that is less than the applicable lifetime
limit.
(C) Rule in case of different limits
In the case of a plan that is not described in subparagraph
(A) or (B) and that includes no or different aggregate lifetime
limits on different categories of medical and surgical
benefits, the Secretary shall establish rules under which
subparagraph (B) is applied to such plan with respect to mental
health benefits by substituting for the applicable lifetime
limit an average aggregate lifetime limit that is computed
taking into account the weighted average of the aggregate
lifetime limits applicable to such categories.
(2) Annual limits
In the case of a group health plan that provides both medical
and surgical benefits and mental health benefits -
(A) No annual limit
If the plan does not include an annual limit on substantially
all medical and surgical benefits, the plan may not impose any
annual limit on mental health benefits.
(B) Annual limit
If the plan includes an annual limit on substantially all
medical and surgical benefits (in this paragraph referred to as
the "applicable annual limit"), the plan shall either -
(i) apply the applicable annual limit both to medical and
surgical benefits to which it otherwise would apply and to
mental health benefits and not distinguish in the application
of such limit between such medical and surgical benefits and
mental health benefits; or
(ii) not include any annual limit on mental health benefits
that is less than the applicable annual limit.
(C) Rule in case of different limits
In the case of a plan that is not described in subparagraph
(A) or (B) and that includes no or different annual limits on
different categories of medical and surgical benefits, the
Secretary shall establish rules under which subparagraph (B) is
applied to such plan with respect to mental health benefits by
substituting for the applicable annual limit an average annual
limit that is computed taking into account the weighted average
of the annual limits applicable to such categories.
(b) Construction
Nothing in this section shall be construed -
(1) as requiring a group health plan to provide any mental
health benefits; or
(2) in the case of a group health plan that provides mental
health benefits, as affecting the terms and conditions (including
cost sharing, limits on numbers of visits or days of coverage,
and requirements relating to medical necessity) relating to the
amount, duration, or scope of mental health benefits under the
plan, except as specifically provided in subsection (a) (in
regard to parity in the imposition of aggregate lifetime limits
and annual limits for mental health benefits).
(c) Exemptions
(1) Small employer exemption
This section shall not apply to any group health plan for any
plan year of a small employer (as defined in section
4980D(d)(2)).
(2) Increased cost exemption
This section shall not apply with respect to a group health
plan if the application of this section to such plan results in
an increase in the cost under the plan of at least 1 percent.
(d) Separate application to each option offered
In the case of a group health plan that offers a participant or
beneficiary two or more benefit package options under the plan, the
requirements of this section shall be applied separately with
respect to each such option.
(e) Definitions
For purposes of this section:
(1) Aggregate lifetime limit
The term "aggregate lifetime limit" means, with respect to
benefits under a group health plan, a dollar limitation on the
total amount that may be paid with respect to such benefits under
the plan with respect to an individual or other coverage unit.
(2) Annual limit
The term "annual limit" means, with respect to benefits under a
group health plan, a dollar limitation on the total amount of
benefits that may be paid with respect to such benefits in a
12-month period under the plan with respect to an individual or
other coverage unit.
(3) Medical or surgical benefits
The term "medical or surgical benefits" means benefits with
respect to medical or surgical services, as defined under the
terms of the plan, but does not include mental health benefits.
(4) Mental health benefits
The term "mental health benefits" means benefits with respect
to mental health services, as defined under the terms of the
plan, but does not include benefits with respect to treatment of
substance abuse or chemical dependency.
(f) Application of section
This section shall not apply to benefits for services furnished -
(1) on or after September 30, 2001, and before January 10,
2002, and
(2) after December 31, 2003.
-SOURCE-
(Added Pub. L. 105-34, title XV, Sec. 1531(a)(4), Aug. 5, 1997, 111
Stat. 1083; amended Pub. L. 107-116, title VII, Sec. 701(c), Jan.
10, 2002, 115 Stat. 2228; Pub. L. 107-147, title VI, Sec. 610(a),
Mar. 9, 2002, 116 Stat. 60.)
-MISC1-
AMENDMENTS
2002 - Subsec. (f). Pub. L. 107-147 amended heading and text of
subsec. (f) generally. Prior to amendment, text read as follows:
"This section shall not apply to benefits for services furnished on
or after December 31, 2002."
Subsec. (f). Pub. L. 107-116 substituted "December 31, 2002" for
"September 30, 2001".
EFFECTIVE DATE OF 2002 AMENDMENT
Pub. L. 107-147, title VI, Sec. 610(b), Mar. 9, 2002, 116 Stat.
60, provided that: "The amendment made by subsection (a) [amending
this section] shall apply to plan years beginning after December
31, 2000."
-End-
-CITE-
26 USC Subchapter C - General Provisions 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter C - General Provisions
-HEAD-
SUBCHAPTER C - GENERAL PROVISIONS
-MISC1-
Sec.
9831. General exceptions.
9832. Definitions.
9833. Regulations.
AMENDMENTS
1997 - Pub. L. 105-34, title XV, Sec. 1531(a)(3), Aug. 5, 1997,
111 Stat. 1081, added subchapter heading and analysis.
-End-
-CITE-
26 USC Sec. 9831 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter C - General Provisions
-HEAD-
Sec. 9831. General exceptions
-STATUTE-
(a) Exception for certain plans
The requirements of this chapter shall not apply to -
(1) any governmental plan, and
(2) any 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 benefits
The requirements of this chapter shall not apply to any group
health plan in relation to its provision of excepted benefits
described in section 9832(c)(1).
(c) Exception for certain benefits if certain conditions met
(1) Limited, excepted benefits
The requirements of this chapter shall not apply to any group
health plan in relation to its provision of excepted benefits
described in section 9832(c)(2) 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 benefits
The requirements of this chapter shall not apply to any group
health plan in relation to its provision of excepted benefits
described in section 9832(c)(3) 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 benefits
The requirements of this chapter shall not apply to any group
health plan in relation to its provision of excepted benefits
described in section 9832(c)(4) if the benefits are provided
under a separate policy, certificate, or contract of insurance.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2080, Sec. 9804; renumbered Sec. 9831 and amended Pub. L.
105-34, title XV, Sec. 1531(a)(2), (b)(1)(B)-(E), Aug. 5, 1997, 111
Stat. 1081, 1084, 1085.)
-MISC1-
AMENDMENTS
1997 - Pub. L. 105-34 renumbered section 9804 of this title as
this section and substituted reference to section 9832 of this
title for reference to section 9805 of this title in subsecs. (b)
and (c)(1) to (3).
EFFECTIVE DATE OF 1997 AMENDMENT
Amendment by Pub. L. 105-34 applicable with respect to group
health plans for plan years beginning on or after Jan. 1, 1998, see
section 1531(c) of Pub. L. 105-34, set out as a note under section
4980D of this title.
-End-
-CITE-
26 USC Sec. 9832 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter C - General Provisions
-HEAD-
Sec. 9832. Definitions
-STATUTE-
(a) Group health plan
For purposes of this chapter, the term "group health plan" has
the meaning given to such term by section 5000(b)(1).
(b) Definitions relating to health insurance
For purposes of this chapter -
(1) Health insurance coverage
(A) In general
Except as provided in subparagraph (B), the term "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
health maintenance organization contract offered by a health
insurance issuer.
(B) No application to certain excepted benefits
In applying subparagraph (A), excepted benefits described in
subsection (c)(1) shall not be treated as benefits consisting
of medical care.
(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, as in effect on the date of the
enactment of this section). Such term does not include a group
health plan.
(3) Health maintenance organization
The 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.
(c) Excepted benefits
For purposes of this chapter, 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 policy
Medicare supplemental health insurance (as defined under
section 1882(g)(1) of the Social Security Act), coverage
supplemental to the coverage provided under chapter 55 of title
10, United States Code, and similar supplemental coverage
provided to coverage under a group health plan.
(d) Other definitions
For purposes of this chapter -
(1) COBRA continuation provision
The term "COBRA continuation provision" means any of the
following:
(A) Section 4980B, other than subsection (f)(1) thereof
insofar as it relates to pediatric vaccines.
(B) Part 6 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1161 et
seq.), other than section 609 of such Act.
(C) Title XXII of the Public Health Service Act.
(2) Governmental plan
The term "governmental plan" has the meaning given such term by
section 414(d).
(3) Medical care
The term "medical care" has the meaning given such term by
section 213(d) determined without regard to -
(A) paragraph (1)(C) thereof, and
(B) so much of paragraph (1)(D) thereof as relates to
qualified long-term care insurance.
(4) Network plan
The term "network plan" means health insurance coverage of a
health insurance issuer under which the financing and delivery of
medical care are provided, in whole or in part, through a defined
set of providers under contract with the issuer.
(5) 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.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2080; Sec. 9805; renumbered Sec. 9832, Pub. L. 105-34, title
XV, Sec. 1531(a)(2), Aug. 5, 1997, 111 Stat. 1081.)
-REFTEXT-
REFERENCES IN TEXT
The Employee Retirement Income Security Act of 1974, referred to
in subsecs. (b)(2) and (d)(1)(B), is Pub. L. 93-406, Sept. 2, 1974,
88 Stat. 832, as amended. Section 514(b)(2) of the Act is
classified to section 1144(b)(2) of Title 29, Labor. Section 609 of
the Act is classified to section 1169 of Title 29. Part 6 of
subtitle B of title I of the Act is classified generally to part 6
(Sec. 1161 et seq.) of subtitle B of subchapter I of chapter 18 of
Title 29. For complete classification of this Act to the Code, see
Short Title note set out under section 1001 of Title 29 and Tables.
The date of the enactment of this section, referred to in subsec.
(b)(2), is the date of enactment of Pub. L. 104-191, which was
approved Aug. 21, 1996.
Section 1882(g)(1) of the Social Security Act, referred to in
subsec. (c)(4), is classified to section 1395ss(g)(1) of Title 42,
The Public Health and Welfare.
The Public Health Service Act, referred to in subsec. (d)(1)(C),
is act July 1, 1944, ch. 373, 58 Stat. 682, as amended. Title XXII
of the Act is classified generally to subchapter XX (Sec. 300bb-1
et seq.) of chapter 6A of Title 42. For complete classification of
this Act to the Code, see Short Title note set out under section
201 of Title 42 and Tables.
-MISC1-
AMENDMENTS
1997 - Pub. L. 105-34 renumbered section 9805 of this title as
this section.
-SECREF-
SECTION REFERRED TO IN OTHER SECTIONS
This section is referred to in sections 35, 4980D, 9801, 9831 of
this title; title 29 sections 1144a, 2918.
-End-
-CITE-
26 USC Sec. 9833 01/19/04
-EXPCITE-
TITLE 26 - INTERNAL REVENUE CODE
Subtitle K - Group Health Plan Requirements
CHAPTER 100 - GROUP HEALTH PLAN REQUIREMENTS
Subchapter C - General Provisions
-HEAD-
Sec. 9833. Regulations
-STATUTE-
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 chapter. The Secretary may promulgate any
interim final rules as the Secretary determines are appropriate to
carry out this chapter.
-SOURCE-
(Added Pub. L. 104-191, title IV, Sec. 401(a), Aug. 21, 1996, 110
Stat. 2082; Sec. 9806; renumbered Sec. 9833, Pub. L. 105-34, title
XV, Sec. 1531(a)(2), Aug. 5, 1997, 111 Stat. 1081.)
-REFTEXT-
REFERENCES IN TEXT
Section 104 of the Health Care Portability and Accountability Act
of 1996, referred to in text, is section 104 of Pub. L. 104-191,
which is set out as a note under section 300gg-92 of Title 42, The
Public Health and Welfare.
-MISC1-
AMENDMENTS
1997 - Pub. L. 105-34 renumbered section 9806 of this title as
this section.
-End-
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