Subpart C - General Provisions

29 USC 1191 - Preemption; State flexibility; construction

(a) Continued applicability of State law with respect to health insurance issuers 

(1) In general 
Subject to paragraph (2) and except as provided in subsection (b) of this section, 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 plans 
Nothing 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 general 
Subject 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) Exceptions 
Only 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) 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) 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) of this title.
(c) Rules of construction 
Except 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) Definitions 
For purposes of this section
(1) State law 
The 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) State 
The 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 USC 1191a - Special rules relating to group health plans

(a) General exception for certain small group health plans 
The requirements of this part (other than section 1185 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 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 individuals beneficiaries may be eligible to receive any such benefit.

29 USC 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 (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, 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 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.

29 USC 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.