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Content Last Revised: 12/30/2004 |
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Code of Federal Regulations Pertaining to U.S. Department of Labor |
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Labor |
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Pension and Welfare Benefits Administration, Department of Labor |
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Rules and Regulations for Group Health Plan Requirements |
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Requirements Relating to Access and Renewability of Coverage, and Limitations on Preexisting Condition Exclusion Periods |
29 CFR 2590.701-2 - Definitions.
- Section Number: 2590.701-2
- Section Name: Definitions.
Unless otherwise provided, the definitions in this section govern in
applying the provisions of Sec. Sec. 2590.701 through 2590.734.
Affiliation period means a period of time that must expire before
health insurance coverage provided by an HMO becomes effective, and
during which the HMO is not required to provide benefits.
COBRA definitions:
(1) COBRA means Title X of the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended.
(2) COBRA continuation coverage means coverage, under a group health
plan, that satisfies an applicable COBRA continuation provision.
(3) COBRA continuation provision means sections 601-608 of the Act,
section 4980B of the Internal Revenue Code (other than paragraph (f)(1)
of such section 4980B insofar as it relates to pediatric vaccines), or
Title XXII of the PHS Act.
(4) Exhaustion of COBRA continuation coverage means that an
individual's COBRA continuation coverage ceases for any reason other
than either failure of the individual to pay premiums on a timely basis,
or for cause (such as making a fraudulent claim or an intentional
misrepresentation of a material fact in connection with the plan). An
individual is considered to have exhausted COBRA continuation coverage
if such coverage ceases--
(i) Due to the failure of the employer or other responsible entity
to remit premiums on a timely basis;
(ii) When the individual no longer resides, lives, or works in the
service area of an HMO or similar program (whether or not within the
choice of the individual) and there is no other
[[Page 636]]
COBRA continuation coverage available to the individual; or
(iii) When the individual incurs a claim that would meet or exceed a
lifetime limit on all benefits and there is no other COBRA continuation
coverage available to the individual.
Condition means a medical condition.
Creditable coverage means creditable coverage within the meaning of
Sec. 2590.701-4(a).
Dependent means any individual who is or may become eligible for
coverage under the terms of a group health plan because of a
relationship to a participant.
Enroll means to become covered for benefits under a group health
plan (that is, when coverage becomes effective), without regard to when
the individual may have completed or filed any forms that are required
in order to become covered under the plan. For this purpose, an
individual who has health coverage under a group health plan is enrolled
in the plan regardless of whether the individual elects coverage, the
individual is a dependent who becomes covered as a result of an election
by a participant, or the individual becomes covered without an election.
Enrollment date definitions (enrollment date, first day of coverage,
and waiting period) are set forth in Sec. 2590.701-3(a)(3)(i), (ii),
and (iii).
Excepted benefits means the benefits described as excepted in Sec.
2590.732(c).
Genetic information means information about genes, gene products,
and inherited characteristics that may derive from the individual or a
family member. This includes information regarding carrier status and
information derived from laboratory tests that identify mutations in
specific genes or chromosomes, physical medical examinations, family
histories, and direct analysis of genes or chromosomes.
Group health insurance coverage means health insurance coverage
offered in connection with a group health plan.
Group health plan or plan means a group health plan within the
meaning of Sec. 2590.732(a).
Group market means the market for health insurance coverage offered
in connection with a group health plan. (However, certain very small
plans may be treated as being in the individual market, rather than the
group market; see the definition of individual market in this section.)
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 HMO contract offered by a health
insurance issuer. Health insurance coverage includes group health
insurance coverage, individual health insurance coverage, and short-
term, limited-duration insurance.
Health insurance issuer or issuer means an insurance company,
insurance service, or insurance organization (including an HMO) that is
required to be licensed to engage in the business of insurance in a
State and that is subject to State law that regulates insurance (within
the meaning of section 514(b)(2) of the Act). Such term does not include
a group health plan.
Health maintenance organization or HMO means--
(1) A federally qualified health maintenance organization (as
defined in section 1301(a) of the PHS Act);
(2) An organization recognized under State law as a health
maintenance organization; or
(3) A similar organization regulated under State law for solvency in
the same manner and to the same extent as such a health maintenance
organization.
Individual health insurance coverage means health insurance coverage
offered to individuals in the individual market, but does not include
short-term, limited-duration insurance. Individual health insurance
coverage can include dependent coverage.
Individual market means the market for health insurance coverage
offered to individuals other than in connection with a group health
plan. Unless a State elects otherwise in accordance with section
2791(e)(1)(B)(ii) of the PHS Act, such term also includes coverage
offered in connection with a group health plan that has fewer than two
participants who are current employees on the first day of the plan
year.
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Internal Revenue Code means the Internal Revenue Code of 1986, as
amended (Title 26, United States Code).
Issuer means a health insurance issuer.
Late enrollment definitions (late enrollee and late enrollment) are
set forth in Sec. 2590.701-3(a)(3)(v) and (vi).
Medical care means amounts paid for--
(1) The diagnosis, cure, mitigation, treatment, or prevention of
disease, or amounts paid for the purpose of affecting any structure or
function of the body;
(2) Transportation primarily for and essential to medical care
referred to in paragraph (1) of this definition; and
(3) Insurance covering medical care referred to in paragraphs (1)
and (2) of this definition.
Medical condition or condition means any condition, whether physical
or mental, including, but not limited to, any condition resulting from
illness, injury (whether or not the injury is accidental), pregnancy, or
congenital malformation. However, genetic information is not a
condition.
Participant means participant within the meaning of section 3(7) of
the Act.
Placement, or being placed, for adoption means the assumption and
retention of a legal obligation for total or partial support of a child
by a person with whom the child has been placed in anticipation of the
child's adoption. The child's placement for adoption with such person
ends upon the termination of such legal obligation.
Plan year means the year that is designated as the plan year in the
plan document of a group health plan, except that if the plan document
does not designate a plan year or if there is no plan document, the plan
year is--
(1) The deductible or limit year used under the plan;
(2) If the plan does not impose deductibles or limits on a yearly
basis, then the plan year is the policy year;
(3) If the plan does not impose deductibles or limits on a yearly
basis, and either the plan is not insured or the insurance policy is not
renewed on an annual basis, then the plan year is the employer's taxable
year; or
(4) In any other case, the plan year is the calendar year.
Preexisting condition exclusion means preexisting condition
exclusion within the meaning of Sec. 2590.701-3(a)(1).
Public health plan means public health plan within the meaning of
Sec. 2590.701-4(a)(1)(ix).
Public Health Service Act (PHS Act) means the Public Health Service
Act (42 U.S.C. 201, et seq.).
Short-term, limited-duration insurance means health insurance
coverage provided pursuant to a contract with an issuer that has an
expiration date specified in the contract (taking into account any
extensions that may be elected by the policyholder without the issuer's
consent) that is less than 12 months after the original effective date
of the contract.
Significant break in coverage means a significant break in coverage
within the meaning of Sec. 2590.701-4(b)(2)(iii).
Special enrollment means enrollment in a group health plan or group
health insurance coverage under the rights described in Sec. 2590.701-
6.
State means each of the several States, the District of Columbia,
Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern
Mariana Islands.
State health benefits risk pool means a State health benefits risk
pool within the meaning of Sec. 2590.701-4(a)(1)(vii).
Waiting period means waiting period within the meaning of Sec.
2590.701-3(a)(3)(iii).
[69 FR 78763, Dec. 30, 2004]
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