§ 1191b TITLE 29—LABOR Page 480

(b) Exception for certain benefits

The 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 benefits

The 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 benefits

The 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 benefits

The 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 partnerships

For purposes of this part—

(1) Treatment as a group health plan

Any 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) Employer

In the case of a group health plan, the term

‘‘employer’’ also includes the partnership in

relation to any partner.

(3) Participants of group health plans

In 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.

(Pub. L. 93–406, title I, §732, formerly §705, as

added Pub. L. 104–191, title I, §101(a), Aug. 21,

1996, 110 Stat. 1948; renumbered §732 and amended Pub. L. 104–204, title VI, §603(a)(3), (b)(2),

(3)(I)–(L), Sept. 26, 1996, 110 Stat. 2935, 2937, 2938.)

AMENDMENTS

1996—Subsec. (a). Pub. L. 104–204, §603(b)(2), inserted

‘‘(other than section 1185 of this title)’’ after ‘‘part’’.

Subsecs. (b), (c)(1) to (3). Pub. L. 104–204,

§603(b)(3)(I)–(L), made technical amendment to references in original act which appear in text as references to section 1191b of this title.

EFFECTIVE DATE OF 1996 AMENDMENT

Amendment by Pub. L. 104–204 applicable with respect to group health plans for plan years beginning on

and after Jan. 1, 1998, see section 603(c) of Pub. L.

104–204, set out as a note under section 1003 of this title.

EFFECTIVE DATE

Section applicable with respect to group health plans

for plan years beginning after June 30, 1997, except as

otherwise provided, see section 101(g) of Pub. L. 104–191,

set out as a note under section 1181 of this title.

§ 1191b. Definitions

(a) Group health plan

For purposes of this part—

(1) In general

The 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.

(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) 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 insurance

For purposes of this part—

(1) Health insurance coverage

The term ‘‘health insurance coverage’’

means benefits consisting of medical care
Page 481 TITLE 29—LABOR § 1191c

(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 1144(b)(2) of

this title). 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.

(4) Group health insurance coverage

The term ‘‘group health insurance coverage’’

means, in connection with a group health

plan, health insurance coverage offered in connection with such plan.

(c) Excepted benefits

For 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, communitybased 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 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 definitions

For purposes of this part—

(1) COBRA continuation provision

The 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 factor

The term ‘‘health status-related factor’’

means any of the factors described in section

1182(a)(1) of this title.

(3) Network plan

The 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 adoption

The term ‘‘placement’’, or being ‘‘placed’’,

for adoption, has the meaning given such term

in section 1169(c)(3)(B) of this title.

(Pub. L. 93–406, title I, §733, formerly §706, as

added Pub. L. 104–191, title I, §101(a), Aug. 21,

1996, 110 Stat. 1949; renumbered §733, Pub. L.

104–204, title VI, §603(a)(3), Sept. 26, 1996, 110

Stat. 2935.)

REFERENCES IN TEXT

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 (§300bb–1 et seq.) of chapter 6A of

Title 42, The Public Health and Welfare. For complete

classification of this Act to the Code, see Short Title

note set out under section 201 of Title 42 and Tables.

EFFECTIVE DATE

Section applicable with respect to group health plans

for plan years beginning after June 30, 1997, except as

otherwise provided, see section 101(g) of Pub. L. 104–191,

set out as a note under section 1181 of this title.

SECTION REFERRED TO IN OTHER SECTIONS

This section is referred to in sections 1003, 1021, 1022,

1024, 1132, 1136, 1181, 1191a of this title.

§ 1191c. Regulations

The Secretary, consistent with section 104 of

the Health Care Portability and Accountability