cfr_sections
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55 rows where part_number = 2590 and title_number = 29 sorted by section_id
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| section_id ▼ | title_number | title_name | chapter | subchapter | part_number | part_name | subpart | subpart_name | section_number | section_heading | agency | authority | source_citation | amendment_citations | full_text |
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| 29:29:9.1.2.12.16.1.11.1 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.606-1 General notice of continuation coverage. | PBGC | [69 FR 30097, May 26, 2004; 69 FR 34921, June 23, 2004] | (a) General. Pursuant to section 606(a)(1) of the Employee Retirement Income Security Act of 1974, as amended (the Act), the administrator of a group health plan subject to the continuation coverage requirements of part 6 of title I of the Act shall provide, in accordance with this section, written notice to each covered employee and spouse of the covered employee (if any) of the right to continuation coverage provided under the plan. (b) Timing of notice. (1) The notice required by paragraph (a) of this section shall be furnished to each employee and each employee's spouse, not later than the earlier of: (i) The date that is 90 days after the date on which such individual's coverage under the plan commences, or, if later, the date that is 90 days after the date on which the plan first becomes subject to the continuation coverage requirements; or (ii) The first date on which the administrator is required, pursuant to § 2590.606-4(b), to furnish the covered employee, spouse, or dependent child of such employee notice of a qualified beneficiary's right to elect continuation coverage. (2) A notice that is furnished in accordance with paragraph (b)(1) of this section shall, for purposes of section 606(a)(1) of the Act, be deemed to be provided at the time of commencement of coverage under the plan. (3) In any case in which an administrator is required to furnish a notice to a covered employee or spouse pursuant to paragraph (b)(1)(ii) of this section, the furnishing of a notice to such individual in accordance with § 2590.606-4(b) shall be deemed to satisfy the requirements of this section. (c) Content of notice. The notice required by paragraph (a) of this section shall be written in a manner calculated to be understood by the average plan participant and shall contain the following information: (1) The name of the plan under which continuation coverage is available, and the name, address and telephone number of a party or parties from whom additional information about the plan and continuation coverage… | |||
| 29:29:9.1.2.12.16.1.11.2 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.606-2 Notice requirement for employers. | PBGC | [69 FR 30097, May 26, 2004] | (a) General. Pursuant to section 606(a)(2) of the Employee Retirement Income Security Act of 1974, as amended (the Act), except as otherwise provided herein, the employer of a covered employee under a group health plan subject to the continuation coverage requirements of part 6 of title I of the Act shall provide, in accordance with this section, notice to the administrator of the plan of the occurrence of a qualifying event that is the covered employee's death, termination of employment (other than by reason of gross misconduct), reduction in hours of employment, Medicare entitlement, or a proceeding in a case under title 11, United States Code, with respect to the employer from whose employment the covered employee retired at any time. (b) Timing of notice. The notice required by this section shall be furnished to the administrator of the plan— (1) In the case of a plan that provides, with respect to a qualifying event, pursuant to section 607(5) of the Act, that continuation coverage and the applicable period for providing notice under section 606(a)(2) of the Act shall commence on the date of loss of coverage, not later than 30 days after the date on which a qualified beneficiary loses coverage under the plan due to the qualifying event; (2) In the case of a multiemployer plan that provides, pursuant to section 606(a)(2) of the Act, for a longer period of time within which employers may provide notice of a qualifying event, not later than the end of the period provided pursuant to the plan's terms for such notice; and (3) In all other cases, not later than 30 days after the date on which the qualifying event occurred. (c) Content of notice. The notice required by this section shall include sufficient information to enable the administrator to determine the plan, the covered employee, the qualifying event, and the date of the qualifying event. (d) Multiemployer plan special rules. This section shall not apply to any employer that maintains a multiemployer plan, with respect to qualifying events a… | |||
| 29:29:9.1.2.12.16.1.11.3 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.606-3 Notice requirements for covered employees and qualified beneficiaries. | PBGC | [69 FR 30097, May 26, 2004] | (a) General. In accordance with the authority of sections 505 and 606(a)(3) of the Employee Retirement Income Security Act of 1974, as amended (the Act), this section sets forth requirements for group health plans subject to the continuation coverage requirements of part 6 of title I of the Act with respect to the responsibility of covered employees and qualified beneficiaries to provide the following notices to administrators: (1) Notice of the occurrence of a qualifying event that is a divorce or legal separation of a covered employee from his or her spouse; (2) Notice of the occurrence of a qualifying event that is a beneficiary's ceasing to be covered under a plan as a dependent child of a participant; (3) Notice of the occurrence of a second qualifying event after a qualified beneficiary has become entitled to continuation coverage with a maximum duration of 18 (or 29) months; (4) Notice that a qualified beneficiary entitled to receive continuation coverage with a maximum duration of 18 months has been determined by the Social Security Administration, under title II or XVI of the Social Security Act (42 U.S.C. 401 et seq. or 1381 et seq. ) (SSA), to be disabled at any time during the first 60 days of continuation coverage; and (5) Notice that a qualified beneficiary, with respect to whom a notice described in paragraph (a)(4) of this section has been provided, has subsequently been determined by the Social Security Administration, under title II or XVI of the SSA to no longer be disabled. (b) Reasonable procedures. (1) A plan subject to the continuation coverage requirements shall establish reasonable procedures for the furnishing of the notices described in paragraph (a) of this section. (2) For purposes of this section, a plan's notice procedures shall be deemed reasonable only if such procedures: (i) Are described in the plan's summary plan description required by § 2520.102-3 of this chapter; (ii) Specify the individual or entity designated to receive such notices; (iii) Specify the mean… | |||
| 29:29:9.1.2.12.16.1.11.4 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.606-4 Notice requirements for plan administrators. | PBGC | [69 FR 30097, May 26, 2004; 69 FR 34921, June 23, 2004] | (a) General. Pursuant to section 606(a)(4) of the Employee Retirement Income Security Act of 1974, as amended (the Act), the administrator of a group health plan subject to the continuation coverage requirements of Part 6 of title I of the Act shall provide, in accordance with this section, notice to each qualified beneficiary of the qualified beneficiary's rights to continuation coverage under the plan. (b) Notice of right to elect continuation coverage. (1) Except as provided in paragraph (b)(2) or (3) of this section, upon receipt of a notice of qualifying event furnished in accordance with § 2590.606-2 or § 2590.606-3, the administrator shall furnish to each qualified beneficiary, not later than 14 days after receipt of the notice of qualifying event, a notice meeting the requirements of paragraph (b)(4) of this section. (2) In the case of a plan with respect to which an employer of a covered employee is also the administrator of the plan, except as provided in paragraph (b)(3) of this section, if the employer is otherwise required to furnish a notice of a qualifying event to an administrator pursuant to § 2590.606-2, the administrator shall furnish to each qualified beneficiary a notice meeting the requirements of paragraph (b)(4) of this section not later than 44 days after: (i) In the case of a plan that provides, with respect to the qualifying event, that continuation coverage and the applicable period for providing notice under section 606(a)(2) of the Act shall commence with the date of loss of coverage, the date on which a qualified beneficiary loses coverage under the plan due to the qualifying event; or (ii) In all other cases, the date on which the qualifying event occurred. (3) In the case of a plan that is a multiemployer plan, a notice meeting the requirements of paragraph (b)(4) of this section shall be furnished not later than the later of: (i) The end of the time period provided in paragraph (b)(1) of this section; or (ii) The end of the time period provided in the terms of the plan… | |||
| 29:29:9.1.2.12.16.1.11.5 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.609-1 [Reserved] | PBGC | |||||
| 29:29:9.1.2.12.16.1.11.6 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | A | Subpart A—Continuation Coverage, Qualified Medical Child Support Orders, Coverage for Adopted Children | § 2590.609-2 National Medical Support Notice. | PBGC | [65 FR 82142, Dec. 27, 2000] | (a) This section promulgates the National Medical Support Notice (the Notice), as mandated by section 401(b) of the Child Support Performance and Incentive Act of 1998 (Pub. L. 105-200). If the Notice is appropriately completed and satisfies paragraphs (3) and (4) of section 609(a) of the Employee Retirement Income Security Act (ERISA), the Notice is deemed to be a qualified medical child support order (QMCSO) pursuant to ERISA section 609(a)(5)(C). Section 609(a) of ERISA delineates the rights and obligations of the alternate recipient (child), the participant, and the group health plan under a QMCSO. A copy of the Notice is available on the Internet at http://www.dol.gov/ebsa. (b) For purposes of this section, a plan administrator shall find that a Notice is appropriately completed if it contains the name of an Issuing Agency, the name and mailing address (if any) of an employee who is a participant under the plan, the name and mailing address of one or more alternate recipient(s) (child(ren) of the participant) (or the name and address of a substituted official or agency which has been substituted for the mailing address of the alternate recipient(s)), and identifies an underlying child support order. (c)(1) Under section 609(a)(3)(A) of ERISA, in order to be qualified, a medical child support order must clearly specify the name and the last known mailing address (if any) of the participant and the name and mailing address of each alternate recipient covered by the order, except that, to the extent provided in the order, the name and mailing address of an official of a State or a political subdivision thereof may be substituted for the mailing address of any such alternate recipient. Section 609(a)(3)(B) of ERISA requires a reasonable description of the type of coverage to be provided to each such alternate recipient, or the manner in which such type of coverage is to be determined. Section 609(a)(3)(C) of ERISA requires that the order specify the period to which such order applies. (2) The Notice satisfie… | |||
| 29:29:9.1.2.12.16.2.11.1 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-1 Basis and scope. | PBGC | [69 FR 78763, Dec. 30, 2004, as amended at 74 FR 51683, Oct. 7, 2009; 79 FR 10308, Feb. 24, 2014] | (a) Statutory basis. This Subpart B implements Part 7 of Subtitle B of Title I of the Employee Retirement Income Security Act of 1974, as amended (hereinafter ERISA or the Act). (b) Scope. A group health plan or health insurance issuer offering group health insurance coverage may provide greater rights to participants and beneficiaries than those set forth in this Subpart B. This Subpart B sets forth minimum requirements for group health plans and group health insurance issuers offering group health insurance coverage concerning certain consumer protections of the Health Insurance Portability and Accountability Act (HIPAA), including special enrollment periods and the prohibition against discrimination based on a health factor, as amended by the Patient Protection and Affordable Care Act (Affordable Care Act). Other consumer protection provisions, including other protections provided by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act, are set forth in Subpart C of this part. | |||
| 29:29:9.1.2.12.16.2.11.10 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.702-1 Additional requirements prohibiting discrimination based on genetic information. | PBGC | [74 FR 51683, Oct. 7, 2009] | (a) Definitions. Unless otherwise provided, the definitions in this paragraph (a) govern in applying the provisions of this section. (1) Collect means, with respect to information, to request, require, or purchase such information. (2) Family member means, with respect to an individual— (i) A dependent (as defined for purposes of § 2590.701-2 of this Part) of the individual; or (ii) Any other person who is a first-degree, second-degree, third-degree, or fourth-degree relative of the individual or of a dependent of the individual. Relatives by affinity (such as by marriage or adoption) are treated the same as relatives by consanguinity (that is, relatives who share a common biological ancestor). In determining the degree of the relationship, relatives by less than full consanguinity (such as half-siblings, who share only one parent) are treated the same as relatives by full consanguinity (such as siblings who share both parents). (A) First-degree relatives include parents, spouses, siblings, and children. (B) Second-degree relatives include grandparents, grandchildren, aunts, uncles, nephews, and nieces. (C) Third-degree relatives include great-grandparents, great-grandchildren, great aunts, great uncles, and first cousins. (D) Fourth-degree relatives include great-great grandparents, great-great grandchildren, and children of first cousins. (3) Genetic information means— (i) Subject to paragraphs (a)(3)(ii) and (a)(3)(iii) of this section, with respect to an individual, information about— (A) The individual's genetic tests (as defined in paragraph (a)(5) of this section); (B) The genetic tests of family members of the individual; (C) The manifestation (as defined in paragraph (a)(6) of this section) of a disease or disorder in family members of the individual; or (D) Any request for, or receipt of, genetic services (as defined in paragraph (a)(4) of this section), or participation in clinical research which includes genetic services, by the individual or any family member of the individual. … | |||
| 29:29:9.1.2.12.16.2.11.11 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.702-2 Special rule allowing integration of Health Reimbursement Arrangements (HRAs) and other account-based group health plans with individual health insurance coverage and Medicare and prohibiting discrimination in HRAs and other account-based group health plans. | PBGC | [84 FR 29001, June 20, 2019] | (a) Scope. This section applies to health reimbursement arrangements (HRAs) and other account-based group health plans, as defined in § 2590.715-2711(d)(6)(i) of this part. For ease of reference, the term “HRA” is used in this section to include other account-based group health plans. For related regulations, see 26 CFR 1.36B-2(c)(3)(i) and (c)(5), 29 CFR 2510.3-1(l), and 45 CFR 155.420. (b) Purpose. This section provides the conditions that an HRA must satisfy in order to be integrated with individual health insurance coverage for purposes of Public Health Service Act (PHS Act) sections 2711 and 2713 and § 2590.715-2711(d)(4) of this part (referred to as an individual coverage HRA). This section also allows an individual coverage HRA to be integrated with Medicare for purposes of PHS Act sections 2711 and 2713 and § 2590.715-2711(d)(4), subject to the conditions provided in this section (see paragraph (e) of this section). Some of the conditions set forth in this section specifically relate to compliance with PHS Act sections 2711 and 2713 and some relate to the effect of having or being offered an individual coverage HRA on eligibility for the premium tax credit under section 36B of the Code. In addition, this section provides conditions that an individual coverage HRA must satisfy in order to comply with the nondiscrimination provisions in ERISA section 702 and PHS Act section 2705 (which is incorporated in ERISA section 715) and that are consistent with the provisions of the Patient Protection and Affordable Care Act, Public Law 111-148 (124 Stat. 119 (2010)), and the Health Care and Education Reconciliation Act of 2010, Public Law 111-152 (124 Stat. 1029 (2010)), each as amended, that are designed to create a competitive individual market. These conditions are intended to prevent an HRA plan sponsor from intentionally or unintentionally, directly or indirectly, steering any participants or dependents with adverse health factors away from its traditional group health plan, if any, and toward individual h… | |||
| 29:29:9.1.2.12.16.2.11.12 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.703 Guaranteed renewability in multiemployer plans and multiple employer welfare arrangements. [Reserved] | PBGC | |||||
| 29:29:9.1.2.12.16.2.11.2 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-2 Definitions. | PBGC | [69 FR 78763, Dec. 30, 2004, as amended at 74 FR 51683, Oct. 7, 2009; 75 FR 37229, June 28, 2010; 79 FR 10308, Feb. 24, 2014; 80 FR 72256, Nov. 18, 2015; 81 FR 75325, Oct. 31, 2016; 83 FR 38242, Aug. 3, 2018; 84 FR 29001, June 20, 2019; 89 FR 23413, Apr. 3, 2024] | Unless otherwise provided, the definitions in this section govern in applying the provisions of §§ 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 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 § 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 rel… | |||
| 29:29:9.1.2.12.16.2.11.3 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-3 Limitations on preexisting condition exclusion period. | PBGC | [69 FR 78763, Dec. 30, 2004, as amended at 75 FR 37229, June 28, 2010; 79 FR 10308, Feb. 24, 2014; 80 FR 72256, Nov. 18, 2015] | (a) Preexisting condition exclusion defined. (1) A preexisting condition exclusion means a preexisting condition exclusion within the meaning of § 2590.701-2. (2) Examples. The rules of this paragraph (a)(1) are illustrated by the following examples: (ii) Conclusion. In this Example 1, the exclusion of benefits for any prosthesis if the body part was lost before the effective date of coverage is a preexisting condition exclusion because it operates to exclude benefits for a condition based on the fact that the condition was present before the effective date of coverage under the policy. The exclusion of benefits, therefore, is prohibited. (ii) Conclusion. In this Example 2, the plan provision excluding cosmetic surgery benefits for individuals injured before enrolling in the plan is a preexisting condition exclusion because it operates to exclude benefits relating to a condition based on the fact that the condition was present before the effective date of coverage. The plan provision, therefore, is prohibited. (ii) Conclusion. In this Example 3, the requirement to obtain advance approval of a treatment plan is a preexisting condition exclusion because it limits benefits for a condition based on the fact that the condition was present before the effective date of coverage. The plan provision, therefore, is prohibited. (ii) Conclusion. In this Example 4, counting benefits for a specific condition provided under prior health coverage against a treatment limit for that condition is a preexisting condition exclusion because it operates to limit benefits for a condition based on the fact that the condition was present before the effective date of coverage. The plan provision, therefore, is prohibited. (ii) Conclusion. In this Example 5, the requirement to be covered under the plan for 12 months to be eligible for pregnancy benefits is a subterfuge for a preexisting condition exclusion because it is designed to exclude benefits for a condition (pregnancy) that arose before the effective… | |||
| 29:29:9.1.2.12.16.2.11.4 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-4 Rules relating to creditable coverage. | PBGC | [69 FR 78763, Dec. 30, 2004, as amended at 79 FR 10309, Feb. 24, 2014] | (a) General rules —(1) Creditable coverage. For purposes of this section, except as provided in paragraph (a)(2) of this section, the term creditable coverage means coverage of an individual under any of the following: (i) A group health plan as defined in § 2590.732(a). (ii) Health insurance coverage as defined in § 2590.701-2 (whether or not the entity offering the coverage is subject to Part 7 of Subtitle B of Title I of the Act, and without regard to whether the coverage is offered in the group market, the individual market, or otherwise). (iii) Part A or B of Title XVIII of the Social Security Act (Medicare). (iv) Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under section 1928 of the Social Security Act (the program for distribution of pediatric vaccines). (v) Title 10 U.S.C. Chapter 55 (medical and dental care for members and certain former members of the uniformed services, and for their dependents; for purposes of Title 10 U.S.C. Chapter 55, uniformed services means the armed forces and the Commissioned Corps of the National Oceanic and Atmospheric Administration and of the Public Health Service). (vi) A medical care program of the Indian Health Service or of a tribal organization. (vii) A State health benefits risk pool. For purposes of this section, a State health benefits risk pool means— (A) An organization qualifying under section 501(c)(26) of the Internal Revenue Code; (B) A qualified high risk pool described in section 2744(c)(2) of the PHS Act; or (C) Any other arrangement sponsored by a State, the membership composition of which is specified by the State and which is established and maintained primarily to provide health coverage for individuals who are residents of such State and who, by reason of the existence or history of a medical condition— ( 1 ) Are unable to acquire medical care coverage for such condition through insurance or from an HMO, or ( 2 ) Are able to acquire such coverage only at a rate which is substant… | |||
| 29:29:9.1.2.12.16.2.11.5 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-5 Evidence of creditable coverage. | PBGC | [79 FR 10309, Feb. 24, 2014] | (a) In general. The rules for providing certificates of creditable coverage and demonstrating creditable coverage have been superseded by the prohibition on preexisting condition exclusions. See § 2590.715-2704 for rules prohibiting the imposition of a preexisting condition exclusion. (b) Applicability. The provisions of this section apply beginning December 31, 2014. | |||
| 29:29:9.1.2.12.16.2.11.6 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-6 Special enrollment periods. | PBGC | [69 FR 78763, Dec. 30, 2004, as amended at 79 FR 10309, Feb. 24, 2014] | (a) Special enrollment for certain individuals who lose coverage —(1) In general. A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, is required to permit current employees and dependents (as defined in § 2590.701-2) who are described in paragraph (a)(2) of this section to enroll for coverage under the terms of the plan if the conditions in paragraph (a)(3) of this section are satisfied. The special enrollment rights under this paragraph (a) apply without regard to the dates on which an individual would otherwise be able to enroll under the plan. (2) Individuals eligible for special enrollment —(i) When employee loses coverage. A current employee and any dependents (including the employee's spouse) each are eligible for special enrollment in any benefit package under the plan (subject to plan eligibility rules conditioning dependent enrollment on enrollment of the employee) if— (A) The employee and the dependents are otherwise eligible to enroll in the benefit package; (B) When coverage under the plan was previously offered, the employee had coverage under any group health plan or health insurance coverage; and (C) The employee satisfies the conditions of paragraph (a)(3)(i), (ii), or (iii) of this section and, if applicable, paragraph (a)(3)(iv) of this section. (ii) When dependent loses coverage . (A) A dependent of a current employee (including the employee's spouse) and the employee each are eligible for special enrollment in any benefit package under the plan (subject to plan eligibility rules conditioning dependent enrollment on enrollment of the employee) if— ( 1 ) The dependent and the employee are otherwise eligible to enroll in the benefit package; ( 2 ) When coverage under the plan was previously offered, the dependent had coverage under any group health plan or health insurance coverage; and ( 3 ) The dependent satisfies the conditions of paragraph (a)(3)(i), (ii), or (iii) of this section and, if applicable, par… | |||
| 29:29:9.1.2.12.16.2.11.7 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-7 HMO affiliation period as an alternative to a preexisting condition exclusion. | PBGC | [79 FR 10309, Feb. 24, 2014] | The rules for HMO affiliation periods have been superseded by the prohibition on preexisting condition exclusions. See § 2590.715-2704 for rules prohibiting the imposition of a preexisting condition exclusion. | |||
| 29:29:9.1.2.12.16.2.11.8 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.701-8 Interaction With the Family and Medical Leave Act. [Reserved] | PBGC | |||||
| 29:29:9.1.2.12.16.2.11.9 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart B—Health Coverage Portability, Nondiscrimination, and Renewability | § 2590.702 Prohibiting discrimination against participants and beneficiaries based on a health factor. | PBGC | [71 FR 75038, Dec. 13, 2006, as amended at 74 FR 51683, Oct. 7, 2009; 78 FR 33181, June 3, 2013; 79 FR 10309, Feb. 24, 2014] | (a) Health factors. (1) The term health factor means, in relation to an individual, any of the following health status-related factors: (i) Health status; (ii) Medical condition (including both physical and mental illnesses), as defined in § 2590.701-2; (iii) Claims experience; (iv) Receipt of health care; (v) Medical history; (vi) Genetic information, as defined in § 2590.702-1(a)(3) of this Part. (vii) Evidence of insurability; or (viii) Disability. (2) Evidence of insurability includes— (i) Conditions arising out of acts of domestic violence; and (ii) Participation in activities such as motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar activities. (3) The decision whether health coverage is elected for an individual (including the time chosen to enroll, such as under special enrollment or late enrollment) is not, itself, within the scope of any health factor. (However, under § 2590.701-6, a plan or issuer must treat special enrollees the same as similarly situated individuals who are enrolled when first eligible.) (b) Prohibited discrimination in rules for eligibility —(1) In general. (i) A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not establish any rule for eligibility (including continued eligibility) of any individual to enroll for benefits under the terms of the plan or group health insurance coverage that discriminates based on any health factor that relates to that individual or a dependent of that individual. This rule is subject to the provisions of paragraph (b)(2) of this section (explaining how this rule applies to benefits), paragraph (d) of this section (containing rules for establishing groups of similarly situated individuals), paragraph (e) of this section (relating to nonconfinement, actively-at-work, and other service requirements), paragraph (f) of this section (relating to wellness programs), and paragraph (g) of this section (permitting… | |||
| 29:29:9.1.2.12.16.3.11.1 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.711 Standards relating to benefits for mothers and newborns. | PBGC | [73 FR 62422, Oct. 20, 2008] | (a) Hospital length of stay —(1) General rule. Except as provided in paragraph (a)(5) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, that provides benefits for a hospital length of stay in connection with childbirth for a mother or her newborn may not restrict benefits for the stay to less than— (i) 48 hours following a vaginal delivery; or (ii) 96 hours following a delivery by cesarean section. (2) When stay begins —(i) Delivery in a hospital. If delivery occurs in a hospital, the hospital length of stay for the mother or newborn child begins at the time of delivery (or in the case of multiple births, at the time of the last delivery). (ii) Delivery outside a hospital. If delivery occurs outside a hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital inpatient in connection with childbirth. The determination of whether an admission is in connection with childbirth is a medical decision to be made by the attending provider. (3) Examples. The rules of paragraphs (a)(1) and (2) of this section are illustrated by the following examples. In each example, the group health plan provides benefits for hospital lengths of stay in connection with childbirth and is subject to the requirements of this section, as follows: (ii) Conclusion. In this Example 1 , the 48-hour period described in paragraph (a)(1)(i) of this section ends at 6 a.m. on June 14. (ii) Conclusion. In this Example 2 , the 48-hour period described in paragraph (a)(1)(i) of this section ends at 7 p.m. on October 3. (ii) Conclusion. In this Example 3 , the hospital length-of-stay requirements of this section do not apply to the child's admission to the hospital because the admission is not in connection with childbirth. (4) Authorization not required —(i) In general. A plan or issuer is prohibited from requiring that a physician or other health care provider obtain authorization from the plan or issuer for prescribin… | |||
| 29:29:9.1.2.12.16.3.11.10 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2713 Coverage of preventive health services. | PBGC | [75 FR 41757, July 19, 2010, as amended at 76 FR 46625, Aug. 3, 2011; 78 FR 39894, July 2, 2013; 80 FR 41345, July 14, 2015; 82 FR 47831, 47861, Oct. 13, 2017; 85 FR 71195, Nov. 6, 2020] | (a) Services —(1) In general. Beginning at the time described in paragraph (b) of this section and subject to § 2590.715-2713A, a group health plan, or a health insurance issuer offering group health insurance coverage, must provide coverage for and must not impose any cost-sharing requirements (such as a copayment, coinsurance, or a deductible) for— (i) Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved (except as otherwise provided in paragraph (c) of this section); (ii) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved (for this purpose, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention); (iii) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration; (iv) With respect to women, such additional preventive care and screenings not described in paragraph (a)(1)(i) of this section as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of section 2713(a)(4) of the Public Health Service Act, subject to 45 CFR 147.131, 147.132, and 147.133; and (v) Any qualifying coronavirus preventive service, which means an item, service, or immunization that is intended to prevent or mitigate coronavirus disease 2019 (COVID-19) and that is, with … | |||
| 29:29:9.1.2.12.16.3.11.11 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2713A Accommodations in connection with coverage of preventive health services. | PBGC | [82 FR 47831, Oct. 13, 2017, as amended at 82 FR 47861, Oct. 13, 2017; 83 FR 57589, Nov. 15, 2018] | (a) Eligible organizations for optional accommodation. An eligible organization is an organization that meets the criteria of paragraphs (a)(1) through (4) of this section. (1) The organization is an objecting entity described in 45 CFR 147.132(a)(1)(i) or (ii), or 45 CFR 147.133(a)(1)(i) or (ii); (2) Notwithstanding its exempt status under 45 CFR 147.132(a) or 147.133(a), the organization voluntarily seeks to be considered an eligible organization to invoke the optional accommodation under paragraph (b) or (c) of this section as applicable; and (3) [Reserved] (4) The organization self-certifies in the form and manner specified by the Secretary or provides notice to the Secretary of the Department of Health and Human Services as described in paragraph (b) or (c) of this section. To qualify as an eligible organization, the organization must make such self-certification or notice available for examination upon request by the first day of the first plan year to which the accommodation in paragraph (b) or (c) of this section applies. The self-certification or notice must be executed by a person authorized to make the certification or provide the notice on behalf of the organization, and must be maintained in a manner consistent with the record retention requirements under section 107 of ERISA. (5) An eligible organization may revoke its use of the accommodation process, and its issuer or third party administrator must provide participants and beneficiaries written notice of such revocation, as specified herein. (i) Transitional rule. If contraceptive coverage is being offered on the date on which these final rules go into effect, by an issuer or third party administrator through the accommodation process, an eligible organization may give 60-days notice pursuant to PHS Act section 2715(d)(4) and § 2590.715-2715(b), if applicable, to revoke its use of the accommodation process (to allow for the provision of notice to plan participants in cases where contraceptive benefits will no longer be provided). Alterna… | |||
| 29:29:9.1.2.12.16.3.11.12 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2714 Eligibility of children until at least age 26. | PBGC | [80 FR 72263, Nov. 18, 2015] | (a) In general. (1) A group health plan, or a health insurance issuer offering group health insurance coverage, that makes available dependent coverage of children must make such coverage available for children until attainment of 26 years of age. (2) The rule of this paragraph (a) is illustrated by the following example: (ii) Conclusion. In this Example, the plan satisfies the requirement of this paragraph (a) with respect to the child. (b) Restrictions on plan definition of dependent —(1) In general. With respect to a child who has not attained age 26, a plan or issuer may not define dependent for purposes of eligibility for dependent coverage of children other than in terms of a relationship between a child and the participant. Thus, for example, a plan or issuer may not deny or restrict dependent coverage for a child who has not attained age 26 based on the presence or absence of the child's financial dependency (upon the participant or any other person); residency with the participant or with any other person; whether the child lives, works, or resides in an HMO's service area or other network service area; marital status; student status; employment; eligibility for other coverage; or any combination of those factors. (Other requirements of Federal or State law, including section 609 of ERISA or section 1908 of the Social Security Act, may require coverage of certain children.) (2) Construction. A plan or issuer will not fail to satisfy the requirements of this section if the plan or issuer limits dependent child coverage to children under age 26 who are described in section 152(f)(1) of the Code. For an individual not described in Code section 152(f)(1), such as a grandchild or niece, a plan may impose additional conditions on eligibility for dependent child health coverage, such as a condition that the individual be a dependent for income tax purposes. (c) Coverage of grandchildren not required. Nothing in this section requires a plan or issuer to make coverage available for the child of … | |||
| 29:29:9.1.2.12.16.3.11.13 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2715 Summary of benefits and coverage and uniform glossary. | PBGC | [80 FR 34307, June 16, 2015, as amended at 81 FR 43455, July 1, 2016] | (a) Summary of benefits and coverage —(1) In general. A group health plan (and its administrator as defined in section 3(16)(A) of ERISA)), and a health insurance issuer offering group health insurance coverage, is required to provide a written summary of benefits and coverage (SBC) for each benefit package without charge to entities and individuals described in this paragraph (a)(1) in accordance with the rules of this section. (i) SBC provided by a group health insurance issuer to a group health plan —(A) Upon application. A health insurance issuer offering group health insurance coverage must provide the SBC to a group health plan (or its sponsor) upon application for health coverage, as soon as practicable following receipt of the application, but in no event later than seven business days following receipt of the application. If an SBC was provided before application pursuant to paragraph (a)(1)(i)(D) of this section (relating to SBCs upon request), this paragraph (a)(1)(i)(A) is deemed satisfied, provided there is no change to the information required to be in the SBC. However, if there has been a change in the information required, a new SBC that includes the changed information must be provided upon application pursuant to this paragraph (a)(1)(i)(A). (B) By first day of coverage (if there are changes). If there is any change in the information required to be in the SBC that was provided upon application and before the first day of coverage, the issuer must update and provide a current SBC to the plan (or its sponsor) no later than the first day of coverage. (C) Upon renewal, reissuance, or reenrollment. If the issuer renews or reissues a policy, certificate, or contract of insurance for a succeeding policy year, or automatically re-enrolls the policyholder or its participants and beneficiaries in coverage, the issuer must provide a new SBC as follows: ( 1 ) If written application is required (in either paper or electronic form) for renewal or reissuance, the SBC must be provided no later th… | |||
| 29:29:9.1.2.12.16.3.11.14 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2715A1 Transparency in coverage—definitions. | PBGC | [85 FR 72300, Nov. 12, 2020] | (a) Scope and definitions —(1) Scope. This section sets forth definitions for the price transparency requirements for group health plans and health insurance issuers offering group health insurance coverage established in this section and §§ 2590.715-2715A2 and 2590.715-2715A3. (2) Definitions. For purposes of this section and §§ 2590.715-2715A2 and 2590.715-2715A3, the following definitions apply: (i) Accumulated amounts means: (A) The amount of financial responsibility a participant or beneficiary has incurred at the time a request for cost-sharing information is made, with respect to a deductible or out-of-pocket limit. If an individual is enrolled in other than self-only coverage, these accumulated amounts shall include the financial responsibility a participant or beneficiary has incurred toward meeting his or her individual deductible or out-of-pocket limit, as well as the amount of financial responsibility that all the individuals enrolled under the plan or coverage have incurred, in aggregate, toward meeting the other than self-only deductible or out-of-pocket limit, as applicable. Accumulated amounts include any expense that counts toward a deductible or out-of-pocket limit (such as a copayment or coinsurance), but exclude any expense that does not count toward a deductible or out-of-pocket limit (such as any premium payment, out-of-pocket expense for out-of-network services, or amount for items or services not covered under the group health plan or health insurance coverage); and (B) To the extent a group health plan or health insurance issuer imposes a cumulative treatment limitation on a particular covered item or service (such as a limit on the number of items, days, units, visits, or hours covered in a defined time period) independent of individual medical necessity determinations, the amount that has accrued toward the limit on the item or service (such as the number of items, days, units, visits, or hours the participant or beneficiary, has used within that time period). (ii) Billed c… | |||
| 29:29:9.1.2.12.16.3.11.15 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2715A2 Transparency in coverage—required disclosures to participants and beneficiaries. | PBGC | [85 FR 72300, Nov. 12, 2020] | (a) Scope and definitions —(1) Scope. This section establishes price transparency requirements for group health plans and health insurance issuers offering group health insurance coverage for the timely disclosure of information about costs related to covered items and services under a group plan or health insurance coverage. (2) Definitions. For purposes of this section, the definitions in § 2590.715-2715A1 apply. (b) Required disclosures to participants and beneficiaries. At the request of a participant or beneficiary who is enrolled in a group health plan, the plan must provide to the participant or beneficiary the information required under paragraph (b)(1) of this section, in accordance with the method and format requirements set forth in paragraph (b)(2) of this section. (1) Required cost-sharing information. The information required under this paragraph (b)(1) is the following cost-sharing information, which is accurate at the time the request is made, with respect to a participant's or beneficiary's cost-sharing liability for covered items and services: (i) An estimate of the participant's or beneficiary's cost-sharing liability for a requested covered item or service furnished by a provider or providers that is calculated based on the information described in paragraphs (b)(1)(ii) through (iv) of this section. (A) If the request for cost-sharing information relates to items and services that are provided within a bundled payment arrangement, and the bundled payment arrangement includes items or services that have a separate cost-sharing liability, the group health plan or health insurance issuer must provide estimates of the cost-sharing liability for the requested covered item or service, as well as an estimate of the cost-sharing liability for each of the items and services in the bundled payment arrangement that have separate cost-sharing liabilities. While group health plans and health insurance issuers are not required to provide estimates of cost-sharing liability for a bundled paymen… | |||
| 29:29:9.1.2.12.16.3.11.16 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2715A3 Transparency in coverage—requirements for public disclosure. | PBGC | [85 FR 72300, Nov. 12, 2020] | (a) Scope and definitions —(1) Scope. This section establishes price transparency requirements for group health plans and health insurance issuers offering group health insurance coverage for the timely disclosure of information about costs related to covered items and services under a group plan or health insurance coverage. (2) Definitions. For purposes of this section, the definitions in § 2590.715-2715A1 apply. (b) Requirements for public disclosure of in-network provider rates for covered items and services, out-of-network allowed amounts and billed charges for covered items and services, and negotiated rates and historical net prices for covered prescription drugs. A group health plan or health insurance issuer must make available on an internet website the information required under paragraph (b)(1) of this section in three machine-readable files, in accordance with the method and format requirements described in paragraph (b)(2) of this section, and that are updated as required under paragraph (b)(3) of this section. (1) Required information. Machine-readable files required under this paragraph (b) that are made available to the public by a group health plan or health insurance issuer must include: (i) An in-network rate machine-readable file that includes the required information under this paragraph (b)(1)(i) for all covered items and services, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which must be reported in the prescription drug machine-readable file pursuant to paragraph (b)(1)(iii) of this section. The in-network rate machine-readable file must include: (A) For each coverage option offered by a group health plan or health insurance issuer, the name and the 14-digit Health Insurance Oversight System (HIOS) identifier, or, if the 14-digit HIOS identifier is not available, the 5-digit HIOS identifier, or if no HIOS identifier is available, the Employer Identification Number (EIN); (B) A billing code, which in the case of prescription… | |||
| 29:29:9.1.2.12.16.3.11.17 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2719 Internal claims and appeals and external review processes. | PBGC | [80 FR 72264, Nov. 18, 2015, as amended at 86 FR 56110, Oct. 7, 2021] | (a) Scope and definitions —(1) Scope —(i) In general. This section sets forth requirements with respect to internal claims and appeals and external review processes for group health plans and health insurance issuers. Paragraph (b) of this section provides requirements for internal claims and appeals processes. Paragraph (c) of this section sets forth rules governing the applicability of State external review processes. Paragraph (d) of this section sets forth a Federal external review process for plans and issuers not subject to an applicable State external review process. Paragraph (e) of this section prescribes requirements for ensuring that notices required to be provided under this section are provided in a culturally and linguistically appropriate manner. Paragraph (f) of this section describes the authority of the Secretary to deem certain external review processes in existence on March 23, 2010 as in compliance with paragraph (c) or (d) of this section. (ii) Application to grandfathered health plans and health insurance coverage. The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans, as defined under § 2590.715-1251. However, the external review process requirements under paragraphs (c) and (d) of this section, and related notice requirements under paragraph (e) of this section, apply to grandfathered health plans or coverage with respect to adverse benefit determinations involving items and services within the scope of the requirements for out-of-network emergency services, nonemergency services performed by nonparticipating providers at participating facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services under ERISA sections 716 and 717 and §§ 2590.716-4 through 2590.716-5 and 2590.717-1. (2) Definitions. For purposes of this section, the following definitions apply— (i) Adverse benefit determination. An adverse benefit determination … | |||
| 29:29:9.1.2.12.16.3.11.18 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2719A Patient protections. | PBGC | [80 FR 72270, Nov. 18, 2015, as amended at 86 FR 36959, July 13, 2021] | (a) Choice of health care professional —(1) Designation of primary care provider —(i) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan or issuer must permit each participant or beneficiary to designate any participating primary care provider who is available to accept the participant or beneficiary. In such a case, the plan or issuer must comply with the rules of paragraph (a)(4) of this section by informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider. (ii) Construction. Nothing in paragraph (a)(1)(i) of this section is to be construed to prohibit the application of reasonable and appropriate geographic limitations with respect to the selection of primary care providers, in accordance with the terms of the plan or coverage, the underlying provider contracts, and applicable State law. (iii) Example. The rules of this paragraph (a)(1) are illustrated by the following example: (ii) Conclusion. In this Example, the plan has satisfied the requirements of paragraph (a) of this section. (2) Designation of pediatrician as primary care provider —(i) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or provides for the designation of a participating primary care provider for a child by a participant or beneficiary, the plan or issuer must permit the participant or beneficiary to designate a physician (allopathic or osteopathic) who specializes in pediatrics (including pediatric subspecialties, based on the scope of that provider's license under applicable State law) as the child's primary care provider if the provider participates in the network of the plan or issuer and is available to accept the child. In such a case, the plan or issuer must comply with the rules of paragraph (a)(4) … | |||
| 29:29:9.1.2.12.16.3.11.2 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.712 Parity in mental health and substance use disorder benefits. | PBGC | [78 FR 68276, Nov. 13, 2013, as amended at 89 FR 77719, Sept. 23, 2024] | (a) Purpose and meaning of terms —(1) Purpose. This section and § 2590.712-1 set forth rules to ensure parity in aggregate lifetime and annual dollar limits, financial requirements, and quantitative and nonquantitative treatment limitations between mental health and substance use disorder benefits and medical/surgical benefits, as required under ERISA section 712. A fundamental purpose of ERISA section 712, this section, and § 2590.712-1 is to ensure that participants and beneficiaries in a group health plan (or health insurance coverage offered by an issuer in connection with a group health plan) that offers mental health or substance use disorder benefits are not subject to more restrictive aggregate lifetime or annual dollar limits, financial requirements, or treatment limitations with respect to those benefits than the predominant dollar limits, financial requirements, or treatment limitations that are applied to substantially all medical/surgical benefits covered by the plan or coverage in the same classification, as further provided in this section and § 2590.712-1. Accordingly, in complying with the provisions of ERISA section 712, this section, and § 2590.712-1, plans and issuers must not design or apply financial requirements and treatment limitations that impose a greater burden on access (that is, are more restrictive) to mental health or substance use disorder benefits under the plan or coverage than they impose on access to medical/surgical benefits in the same classification of benefits. The provisions of ERISA section 712, this section, and § 2590.712-1 should be interpreted in a manner that is consistent with the purpose described in this paragraph (a)(1). (2) Meaning of terms. For purposes of this section and § 2590.712-1, except where the context clearly indicates otherwise, the following terms have the meanings indicated: Aggregate lifetime dollar limit means a dollar limitation on the total amount of specified benefits that may be paid under a group health plan (or health insurance cov… | |||
| 29:29:9.1.2.12.16.3.11.3 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.712-1 Nonquantitative treatment limitation comparative analysis requirements. | PBGC | [89 FR 77731, Sept. 23, 2024] | (a) Meaning of terms. Unless otherwise stated in this section, the terms of this section have the meanings indicated in § 2590.712(a)(2). (b) In general. In the case of a group health plan (or health insurance issuer offering coverage in connection with a group health plan) that provides both medical/surgical benefits and mental health or substance use disorder benefits and that imposes any nonquantitative treatment limitation on mental health or substance use disorder benefits, the plan or issuer must perform and document a comparative analysis of the design and application of each nonquantitative treatment limitation applicable to mental health or substance use disorder benefits. Each comparative analysis must comply with the content requirements of paragraph (c) of this section and be made available to the Secretary, upon request, in the manner required by paragraphs (d) and (e) of this section. (c) Comparative analysis content requirements. With respect to each nonquantitative treatment limitation applicable to mental health or substance use disorder benefits under a group health plan (or health insurance coverage offered in connection with a group health plan), the comparative analysis performed by the plan or issuer must include, at minimum, the elements specified in this paragraph (c). In addition to the comparative analysis for each nonquantitative treatment limitation, each plan or issuer must prepare and make available to the Secretary, upon request, a written list of all nonquantitative treatment limitations imposed under the plan or coverage, which must be provided to the named fiduciaries of the plan who are required to include a certification as part of each comparative analysis, as required under paragraph (c)(6)(vi) of this section. (1) Description of the nonquantitative treatment limitation. The comparative analysis must include, with respect to the nonquantitative treatment limitation that is the subject of the comparative analysis: (i) Identification of the nonquantitative treatment… | |||
| 29:29:9.1.2.12.16.3.11.4 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-1251 Preservation of right to maintain existing coverage. | PBGC | [80 FR 72256, Nov. 18, 2015, as amended at 85 FR 81118, Dec. 15, 2020] | (a) Definition of grandfathered health plan coverage —(1) In general —(i) Grandfathered health plan coverage means coverage provided by a group health plan, or a health insurance issuer, in which an individual was enrolled on March 23, 2010 (for as long as it maintains that status under the rules of this section). A group health plan or group health insurance coverage does not cease to be grandfathered health plan coverage merely because one or more (or even all) individuals enrolled on March 23, 2010 cease to be covered, provided that the plan or group health insurance coverage has continuously covered someone since March 23, 2010 (not necessarily the same person, but at all times at least one person). In addition, subject to the limitation set forth in paragraph (a)(1)(ii) of this section, a group health plan (and any health insurance coverage offered in connection with the group health plan) does not cease to be a grandfathered health plan merely because the plan (or its sponsor) enters into a new policy, certificate, or contract of insurance after March 23, 2010 (for example, a plan enters into a contract with a new issuer or a new policy is issued with an existing issuer). For purposes of this section, a plan or health insurance coverage that provides grandfathered health plan coverage is referred to as a grandfathered health plan. The rules of this section apply separately to each benefit package made available under a group health plan or health insurance coverage. Accordingly, if any benefit package relinquishes grandfather status, it will not affect the grandfather status of the other benefit packages. (ii) Changes in group health insurance coverage. Subject to paragraphs (f) and (g)(2) of this section, if a group health plan (including a group health plan that was self-insured on March 23, 2010) or its sponsor enters into a new policy, certificate, or contract of insurance after March 23, 2010 that is effective before November 15, 2010, then the plan ceases to be a grandfathered health plan. (2)… | |||
| 29:29:9.1.2.12.16.3.11.5 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2704 Prohibition of preexisting condition exclusions. | PBGC | [80 FR 72261, Nov. 18, 2015] | (a) No preexisting condition exclusions. A group health plan, or a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion (as defined in § 2590.701-2). (b) Examples. The rules of paragraph (a) of this section are illustrated by the following examples (for additional examples illustrating the definition of a preexisting condition exclusion, see § 2590.701-3(a)(2)): (ii) Conclusion. In this Example 1, the exclusion of benefits for oral surgery required as a result of a traumatic injury if the injury occurred before the effective date of coverage is a preexisting condition exclusion because it operates to exclude benefits for a condition based on the fact that the condition was present before the effective date of coverage under the policy. Therefore, such an exclusion is prohibited. (ii) Conclusion. See Example 2 in 45 CFR 147.108(a)(2) for a conclusion that M 's denial of C 's application for coverage is a preexisting condition exclusion because a denial of an application for coverage based on the fact that a condition was present before the date of denial is an exclusion of benefits based on a preexisting condition. Therefore, such an exclusion is prohibited. (c) Applicability date. The provisions of this section are applicable to group health plans and health insurance issuers for plan years beginning on or after January 1, 2017. Until the applicability date for this regulation, plans and issuers are required to continue to comply with the corresponding sections of 29 CFR part 2590, contained in the 29 CFR, parts 1927 to end, edition revised as of July 1, 2015. | |||
| 29:29:9.1.2.12.16.3.11.6 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2705 Prohibiting discrimination against participants and beneficiaries based on a health factor. | PBGC | [78 FR 33186, June 3, 2013] | (a) In general. A group health plan and a health insurance issuer offering group health insurance coverage must comply with the requirements of § 2590.702 of this part. (b) Applicability date. This section is applicable to group health plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after January 1, 2014. | |||
| 29:29:9.1.2.12.16.3.11.7 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2708 Prohibition on waiting periods that exceed 90 days. | PBGC | [79 FR 10311, Feb. 24, 2014, as amended at 79 FR 35947, June 25, 2014] | (a) General rule. A group health plan, and a health insurance issuer offering group health insurance coverage, must not apply any waiting period that exceeds 90 days, in accordance with the rules of this section. If, under the terms of a plan, an individual can elect coverage that would begin on a date that is not later than the end of the 90-day waiting period, this paragraph (a) is considered satisfied. Accordingly, in that case, a plan or issuer will not be considered to have violated this paragraph (a) solely because individuals take, or are permitted to take, additional time (beyond the end of the 90-day waiting period) to elect coverage. (b) Waiting period defined. For purposes of this part, a waiting period is the period that must pass before coverage for an individual who is otherwise eligible to enroll under the terms of a group health plan can become effective. If an individual enrolls as a late enrollee (as defined under § 2590.701-2) or special enrollee (as described in § 2590.701-6), any period before such late or special enrollment is not a waiting period. (c) Relation to a plan's eligibility criteria —(1) In general. Except as provided in paragraphs (c)(2) and (c)(3) of this section, being otherwise eligible to enroll under the terms of a group health plan means having met the plan's substantive eligibility conditions (such as, for example, being in an eligible job classification, achieving job-related licensure requirements specified in the plan's terms, or satisfying a reasonable and bona fide employment-based orientation period). Moreover, except as provided in paragraphs (c)(2) and (c)(3) of this section, nothing in this section requires a plan sponsor to offer coverage to any particular individual or class of individuals (including, for example, part-time employees). Instead, this section prohibits requiring otherwise eligible individuals to wait more than 90 days before coverage is effective. See also section 4980H of the Code and its implementing regulations for an applicable larg… | |||
| 29:29:9.1.2.12.16.3.11.8 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2711 No lifetime or annual limits. | PBGC | [80 FR 72261, Nov. 18, 2015, as amended at 81 FR 75325, Oct. 31, 2016; 84 FR 29011, June 20, 2019] | (a) Prohibition —(1) Lifetime limits. Except as provided in paragraph (b) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, may not establish any lifetime limit on the dollar amount of essential health benefits for any individual, whether provided in-network or out-of-network. (2) Annual limits —(i) General rule. Except as provided in paragraphs (a)(2)(ii) and (b) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, may not establish any annual limit on the dollar amount of essential health benefits for any individual, whether provided in-network or out-of-network. (ii) Exception for health flexible spending arrangements. A health flexible spending arrangement (as defined in section 106(c)(2) of the Internal Revenue Code) offered through a cafeteria plan pursuant to section 125 of the Internal Revenue Code is not subject to the requirement in paragraph (a)(2)(i) of this section. (b) Construction —(1) Permissible limits on specific covered benefits. The rules of this section do not prevent a group health plan, or a health insurance issuer offering group health insurance coverage, from placing annual or lifetime dollar limits with respect to any individual on specific covered benefits that are not essential health benefits to the extent that such limits are otherwise permitted under applicable Federal or State law. (The scope of essential health benefits is addressed in paragraph (c) of this section). (2) Condition-based exclusions. The rules of this section do not prevent a group health plan, or a health insurance issuer offering group health insurance coverage, from excluding all benefits for a condition. However, if any benefits are provided for a condition, then the requirements of this section apply. Other requirements of Federal or State law may require coverage of certain benefits. (c) Definition of essential health benefits. The term “essential health benefits” means essenti… | |||
| 29:29:9.1.2.12.16.3.11.9 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | C | Subpart C—Other Requirements | § 2590.715-2712 Rules regarding rescissions. | PBGC | [80 FR 72263, Nov. 18, 2015] | (a) Prohibition on rescissions. (1) A group health plan, or a health insurance issuer offering group health insurance coverage, must not rescind coverage under the plan, or under the policy, certificate, or contract of insurance, with respect to an individual (including a group to which the individual belongs or family coverage in which the individual is included) once the individual is covered under the plan or coverage, unless the individual (or a person seeking coverage on behalf of the individual) performs an act, practice, or omission that constitutes fraud, or makes an intentional misrepresentation of material fact, as prohibited by the terms of the plan or coverage. A group health plan, or a health insurance issuer offering group health insurance coverage, must provide at least 30 days advance written notice to each participant who would be affected before coverage may be rescinded under this paragraph (a)(1), regardless of whether the coverage is insured or self-insured, or whether the rescission applies to an entire group or only to an individual within the group. (The rules of this paragraph (a)(1) apply regardless of any contestability period that may otherwise apply.) (2) For purposes of this section, a rescission is a cancellation or discontinuance of coverage that has retroactive effect. For example, a cancellation that treats a policy as void from the time of the individual's or group's enrollment is a rescission. As another example, a cancellation that voids benefits paid up to a year before the cancellation is also a rescission for this purpose. A cancellation or discontinuance of coverage is not a rescission if— (i) The cancellation or discontinuance of coverage has only a prospective effect; (ii) The cancellation or discontinuance of coverage is effective retroactively to the extent it is attributable to a failure to timely pay required premiums or contributions (including COBRA premiums) towards the cost of coverage; (iii) The cancellation or discontinuance of coverage is initiated by th… | |||
| 29:29:9.1.2.12.16.4.11.1 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-1 Basis and scope. | PBGC | [86 FR 36959, July 13, 2021, as amended at 86 FR 56111, Oct. 7, 2021; 86 FR 66699, Nov. 23, 2021] | (a) Basis. Sections 2590.716-1 through 2590.725-4 implement sections 716-725 of ERISA. (b) Scope. This part establishes standards for group health plans, and health insurance issuers offering group or individual health insurance coverage with respect to surprise medical bills, transparency in health care coverage, and additional patient protections. This part also establishes an independent dispute resolution process, and standards for certifying independent dispute resolution entities. | |||
| 29:29:9.1.2.12.16.4.11.10 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.717-2 Independent dispute resolution process for air ambulance services. | PBGC | [86 FR 56121, Oct. 7, 2021, as amended at 87 FR 52651, Aug. 26, 2022] | (a) Definitions. Unless otherwise stated, the definitions in § 2590.716-3 apply. (b) Determination of out-of-network rates to be paid by health plans and health insurance issuers; independent dispute resolution process —(1) In general. Except as provided in paragraphs (b)(2) and (3) of this section, in determining the out-of-network rate to be paid by group health plans and health insurance issuers offering group health insurance coverage for out-of-network air ambulance services, plans and issuers must comply with the requirements of § 2590.716-8, except that references in § 2590.716-8 to the additional circumstances in § 2590.716-8(c)(4)(iii)(B) shall be understood to refer to paragraph (b)(2) of this section. (2) Considerations for air ambulance services. In determining which offer to select, in addition to considering the applicable qualifying payment amount(s), the certified IDR entity must consider information submitted by a party that relates to the following circumstances: (i) The quality and outcomes measurements of the provider that furnished the services. (ii) The acuity of the condition of the participant or beneficiary receiving the service, or the complexity of furnishing the service to the participant or beneficiary. (iii) The training, experience, and quality of the medical personnel that furnished the air ambulance services. (iv) Ambulance vehicle type, including the clinical capability level of the vehicle. (v) Population density of the point of pick-up (as defined in 42 CFR 414.605) for the air ambulance (such as urban, suburban, rural, or frontier). (vi) Demonstrations of good faith efforts (or lack thereof) made by the nonparticipating provider of air ambulance services or the plan or issuer to enter into network agreements with each other and, if applicable, contracted rates between the provider of air ambulance services and the plan or issuer, as applicable, during the previous 4 plan years. (3) Weighing considerations. In weighing the considerations described in paragraph… | |||
| 29:29:9.1.2.12.16.4.11.11 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.722 Choice of health care professional. | PBGC | (a) Choice of health care professional —(1) Designation of primary care provider —(i) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or provides for designation by a participant or beneficiary of a participating primary care provider, then the plan or issuer must permit each participant or beneficiary to designate any participating primary care provider who is available to accept the participant or beneficiary. In such a case, the plan or issuer must comply with the rules of paragraph (a)(4) of this section by informing each participant of the terms of the plan or health insurance coverage regarding designation of a primary care provider. (ii) Construction. Nothing in paragraph (a)(1)(i) of this section is to be construed to prohibit the application of reasonable and appropriate geographic limitations with respect to the selection of primary care providers, in accordance with the terms of the plan or coverage, the underlying provider contracts, and applicable State law. (iii) Example. The rules of this paragraph (a)(1) are illustrated by the following example: (A) Facts. A group health plan requires individuals covered under the plan to designate a primary care provider. The plan permits each individual to designate any primary care provider participating in the plan's network who is available to accept the individual as the individual's primary care provider. If an individual has not designated a primary care provider, the plan designates one until the individual has made a designation. The plan provides a notice that satisfies the requirements of paragraph (a)(4) of this section regarding the ability to designate a primary care provider. (B) Conclusion. In this Example, the plan has satisfied the requirements of paragraph (a) of this section. (2) Designation of pediatrician as primary care provider —(i) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, requires or p… | ||||
| 29:29:9.1.2.12.16.4.11.12 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.725-1 Definitions. | PBGC | [86 FR 66699, Nov. 23, 2021] | For purposes of this section, the following definitions apply in addition to the definitions in § 2590.716-3: Brand prescription drug means a drug for which an application is approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(c)) or under section 351 of the Public Health Service Act (42 U.S.C. 262), and that is generally marketed under a proprietary, trademark-protected name. The term “brand prescription drug” includes a drug with Emergency Use Authorization issued pursuant to section 564 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360bbb-3), and that is generally marketed under a proprietary, trademark-protected name. The term “brand prescription drug” includes drugs that the U.S. Food and Drug Administration determines to be interchangeable biosimilar products under sections 351(i)(3) and 351(k)(4) of the PHS Act (42 U.S.C. 262). Dosage unit means the smallest form in which a pharmaceutical product is administered or dispensed, such as a pill, tablet, capsule, ampule, or measurement of grams or milliliters. Federal Employees Health Benefits (FEHB) line of business refers to all health benefit plans that are offered to eligible enrollees pursuant to a contract between the Office of Personnel Management and Federal Employees Health Benefits (FEHB) Program carriers. Such plans are Federal governmental plans offered pursuant to 5 U.S.C. chapter 89. Life-years means the total number of months of coverage for participants and beneficiaries, as applicable, divided by 12. Market segment means one of the following: The individual market (excluding the student market), the student market, the fully-insured small group market, the fully-insured large group market (excluding the FEHB line of business), self-funded plans offered by small employers, self-funded plans offered by large employers, and the FEHB line of business. Premium amount means, with respect to fully-insured group health plans, earned premium as that term is defined in 45 CFR 158.130, excluding th… | |||
| 29:29:9.1.2.12.16.4.11.13 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.725-2 Reporting requirements related to prescription drug and health care spending. | PBGC | [86 FR 66699, Nov. 23, 2021] | (a) General requirement. A group health plan or a health insurance issuer offering group health insurance coverage must submit an annual report to the Secretary, the Secretary of the Treasury, and the Secretary of Health and Human Services, on prescription drug and health care spending, premiums, and enrollment under the plan or coverage. (b) Timing and form of report. The report for the 2020 reference year must be submitted to the Secretary by December 27, 2021. Beginning with the 2021 reference year, the report for each reference year is due by June 1 of the year following the reference year. The report must be submitted in the form and manner prescribed by the Secretary, jointly with the Secretary of the Treasury and the Secretary of Health and Human Services. (c) Transfer of business. Issuers that acquire a line or block of business from another issuer during a reference year are responsible for submitting the information and report required by this section for the acquired business for that reference year, including for the part of the reference year that was prior to the acquisition. (d) Reporting entities and special rules to prevent unnecessary duplication —(1) Special rule for insured group health plans. To the extent coverage under a group health plan consists of group health insurance coverage, the plan may satisfy the requirements of paragraph (a) of this section if the plan requires the health insurance issuer offering the coverage to report the information required by this section in compliance with this subpart pursuant to a written agreement. Accordingly, if a health insurance issuer and a group health plan sponsor enter into a written agreement under which the issuer agrees to provide the information required under paragraph (a) of this section in compliance with this section, and the issuer fails to do so, then the issuer, but not the plan, violates the reporting requirements of paragraph (a) of this section with respect to the relevant information. (2) Other contractual arrangemen… | |||
| 29:29:9.1.2.12.16.4.11.14 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.725-3 Aggregate reporting. | PBGC | [86 FR 66699, Nov. 23, 2021] | (a) General requirement. A group health plan or a health insurance issuer offering group health insurance coverage must submit, or arrange to be submitted, the information required in § 2590.725-4(b) of this section separately for each State in which group health coverage or group health insurance coverage was provided in connection with the group health plan or by the health insurance issuer. The report must include the experience of all plans and policies in the State during the reference year covered by the report, and must include the experience separately for each market segment as defined in § 2590.725-1 of this section. (b) Aggregation by reporting entity —(1) In general. If a reporting entity submits data on behalf of more than one group health plan in a State and market segment, the reporting entity may aggregate the data required in § 2590.725-4(b) of this section for the group health plans for each market segment in the State. (2) Multiple reporting entities. (i) If multiple reporting entities submit the required data related to one or more plans or issuers in a State and market segment, the data submitted by each of these reporting entities must not be aggregated at a less granular level than the aggregation level used by the reporting entity that submits the data on total annual spending on health care services, as required by § 2590.725-4(b)(4), on behalf of these plans or issuers. (ii) The Secretary, jointly with the Secretary of the Treasury and the Secretary of Health and Human Services, may specify in guidance alternative or additional aggregation methods for data submitted by multiple reporting entities, to ensure a balance between compliance burdens and a data aggregation level that facilitates the development of the biannual public report required under section 725(b) of ERISA. (3) Group health insurance coverage with dual contracts. If a group health plan involves health insurance coverage obtained from two affiliated issuers, one providing in-network coverage only and the secon… | |||
| 29:29:9.1.2.12.16.4.11.15 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.725-4 Required information. | PBGC | [86 FR 66699, Nov. 23, 2021] | (a) Information for each plan or coverage. The report required under § 2590.725-2 must include the following information for each plan or coverage, at the plan or coverage level: (1) The identifying information for plans, issuers, plan sponsors, and any other reporting entities. (2) The beginning and end dates of the plan year that ended on or before the last day of the reference year. (3) The number of participants and beneficiaries, as applicable, covered on the last day of the reference year. (4) Each State in which the plan or coverage is offered. (b) Information for each state and market segment. The report required under § 2590.725-2 must include the following information with respect to plans or coverage for each State and market segment for the reference year, unless otherwise specified: (1) The 50 brand prescription drugs most frequently dispensed by pharmacies, and for each such drug, the data elements listed in paragraph (b)(5) of this section. The most frequently dispensed drugs must be determined according to total number of paid claims for prescriptions filled during the reference year for each drug. (2) The 50 most costly prescription drugs and for each such drug, the data elements listed in paragraph (b)(5) of this section. The most costly drugs must be determined according to total annual spending on each drug. (3) The 50 prescription drugs with the greatest increase in expenditures between the year immediately preceding the reference year and the reference year, and for each such drug: The data elements listed in paragraph (b)(5) of this section for the year immediately preceding the reference year, and the data elements listed in paragraph (b)(5) of this section for the reference year. The drugs with the greatest increase in expenditures must be determined based on the increase in total annual spending from the year immediately preceding the reference year to the reference year. A drug must be approved for marketing or issued an Emergency Use Authorization by the Food and Drug Admin… | |||
| 29:29:9.1.2.12.16.4.11.2 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-2 Applicability. | PBGC | [86 FR 36959, July 13, 2021, as amended at 86 FR 66699, Nov. 23, 2021] | (a) In general. (1) The requirements in §§ 2590.716-4 through 2590.716-7, 2590.717-1, 2590.722, and 2590.725-1 through 2590.725-4 apply to group health plans and health insurance issuers offering group health insurance coverage (including grandfathered health plans as defined in § 2590.715-1251), except as specified in paragraph (b) of this section. (2) The requirements in §§ 2590.716-8 and 2590.717-2 apply to certified IDR entities and group health plans and health insurance issuers offering group health insurance coverage (including grandfathered health plans as defined in § 2590.715-1251) except as specified in paragraph (b) of this section. (b) Exceptions. The requirements in §§ 2590.716-4 through 2590.716-8, 2590.717-1, 2590.717-2, 2590.722, and 2590.725-1 through 2590.725-4 do not apply to the following: (1) Excepted benefits as described in § 2590.732. (2) Short-term, limited-duration insurance as defined in § 2590.701-2. (3) Health reimbursement arrangements or other account-based group health plans as described in § 2590.715-2711(d). | |||
| 29:29:9.1.2.12.16.4.11.3 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-3 Definitions. | PBGC | The definitions in this part apply to §§ 2590.716 through 2590.722, unless otherwise specified. In addition, for purposes of §§ 2590.716 through 2590.722, the following definitions apply: Air ambulance service means medical transport by a rotary wing air ambulance, as defined in 42 CFR 414.605, or fixed wing air ambulance, as defined in 42 CFR 414.605, for patients. Cost sharing means the amount a participant or beneficiary is responsible for paying for a covered item or service under the terms of the group health plan or health insurance coverage. Cost sharing generally includes copayments, coinsurance, and amounts paid towards deductibles, but does not include amounts paid towards premiums, balance billing by out-of-network providers, or the cost of items or services that are not covered under a group health plan or health insurance coverage. Emergency department of a hospital includes a hospital outpatient department that provides emergency services. Emergency medical condition has the meaning given the term in § 2590.716-4(c)(1). Emergency services has the meaning given the term in § 2590.716-4(c)(2). Health care facility, with respect to a group health plan or group health insurance coverage, in the context of non-emergency services, is each of the following: (1) A hospital (as defined in section 1861(e) of the Social Security Act); (2) A hospital outpatient department; (3) A critical access hospital (as defined in section 1861(mm)(1) of the Social Security Act); and (4) An ambulatory surgical center described in section 1833(i)(1)(A) of the Social Security Act. Independent freestanding emergency department means a health care facility (not limited to those described in the definition of health care facility with respect to non-emergency services) that— (1) Is geographically separate and distinct and licensed separately from a hospital under applicable State law; and (2) Provides any emergency services as described in § 2590.716-4(c)(2)(i). Nonparticipating emergency facility means an e… | ||||
| 29:29:9.1.2.12.16.4.11.4 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-4 Preventing surprise medical bills for emergency services. | PBGC | (a) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, provides or covers any benefits with respect to services in an emergency department of a hospital or with respect to emergency services in an independent freestanding emergency department, the plan or issuer must cover emergency services, as defined in paragraph (c)(2) of this section, and this coverage must be provided in accordance with paragraph (b) of this section. (b) Coverage requirements. A plan or issuer described in paragraph (a) of this section must provide coverage for emergency services in the following manner— (1) Without the need for any prior authorization determination, even if the services are provided on an out-of-network basis. (2) Without regard to whether the health care provider furnishing the emergency services is a participating provider or a participating emergency facility, as applicable, with respect to the services. (3) If the emergency services are provided by a nonparticipating provider or a nonparticipating emergency facility— (i) Without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from participating providers and participating emergency facilities. (ii) Without imposing cost-sharing requirements that are greater than the requirements that would apply if the services were provided by a participating provider or a participating emergency facility. (iii) By calculating the cost-sharing requirement as if the total amount that would have been charged for the services by such participating provider or participating emergency facility were equal to the recognized amount for such services. (iv) The plan or issuer— (A) Not later than 30 calendar days after the bill for the services is transmitted by the provider or facility (or, in cases where the recognized amount is determined by a specified State law or All-Payer Model Agreement, such other t… | ||||
| 29:29:9.1.2.12.16.4.11.5 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-5 Preventing surprise medical bills for non-emergency services performed by nonparticipating providers at certain participating facilities. | PBGC | (a) In general. If a group health plan, or a health insurance issuer offering group health insurance coverage, provides or covers any benefits with respect to items and services described in paragraph (b) of this section, the plan or issuer must cover the items and services when furnished by a nonparticipating provider in accordance with paragraph (c) of this section. (b) Items and services described. The items and services described in this paragraph (b) are items and services (other than emergency services) furnished to a participant or beneficiary by a nonparticipating provider with respect to a visit at a participating health care facility, unless the provider has satisfied the notice and consent criteria of 45 CFR 149.420(c) through (i) with respect to such items and services. (c) Coverage requirements. In the case of items and services described in paragraph (b) of this section, the plan or issuer— (1) Must not impose a cost-sharing requirement for the items and services that is greater than the cost-sharing requirement that would apply if the items or services had been furnished by a participating provider. (2) Must calculate the cost-sharing requirements as if the total amount that would have been charged for the items and services by such participating provider were equal to the recognized amount for the items and services. (3) Not later than 30 calendar days after the bill for the items or services is transmitted by the provider (or in cases where the recognized amount is determined by a specified State law or All-Payer Model Agreement, such other timeframe as specified under the State law or All-Payer Model Agreement), must determine whether the items and services are covered under the plan or coverage and, if the items and services are covered, send to the provider an initial payment or a notice of denial of payment. For purposes of this paragraph (c)(3), the 30-calendar-day period begins on the date the plan or issuer receives the information necessary to decide a claim for payment for the… | ||||
| 29:29:9.1.2.12.16.4.11.6 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-6 Methodology for calculating qualifying payment amount. | PBGC | [86 FR 36959, July 13, 2021, as amended at 87 FR 52648, Aug. 26, 2022] | (a) Definitions. For purposes of this section, the following definitions apply: (1) Contracted rate means the total amount (including cost sharing) that a group health plan or health insurance issuer has contractually agreed to pay a participating provider, facility, or provider of air ambulance services for covered items and services, whether directly or indirectly, including through a third-party administrator or pharmacy benefit manager. Solely for purposes of this definition, a single case agreement, letter of agreement, or other similar arrangement between a provider, facility, or air ambulance provider and a plan or issuer, used to supplement the network of the plan or coverage for a specific participant or beneficiary in unique circumstances, does not constitute a contract. (2) Derived amount has the meaning given the term in § 2590.715-2715A1. (3) Eligible database means— (i) A State all-payer claims database; or (ii) Any third-party database which— (A) Is not affiliated with, or owned or controlled by, any health insurance issuer, or a health care provider, facility, or provider of air ambulance services (or any member of the same controlled group as, or under common control with, such an entity). For purposes of this paragraph (a)(3)(ii)(A), the term controlled group means a group of two or more persons that is treated as a single employer under sections 52(a), 52(b), 414(m), or 414(o) of the Internal Revenue Code of 1986, as amended; (B) Has sufficient information reflecting in-network amounts paid by group health plans or health insurance issuers offering group health insurance coverage to providers, facilities, or providers of air ambulance services for relevant items and services furnished in the applicable geographic region; and (C) Has the ability to distinguish amounts paid to participating providers and facilities by commercial payers, such as group health plans and health insurance issuers offering group health insurance coverage, from all other claims data, such as amounts bill… | |||
| 29:29:9.1.2.12.16.4.11.7 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-7 Complaints process for surprise medical bills regarding group health plans and group health insurance coverage. | PBGC | (a) Scope and definitions —(1) Scope. This section establishes a process to receive and resolve complaints regarding information that a specific group health plan or health insurance issuer offering group health insurance coverage may be failing to meet the requirements under subpart D of this part, which may warrant an investigation. (2) Definitions. In this section— (i) Complaint means a communication, written or oral, that indicates there has been a potential violation of the requirements under subpart D of this part, whether or not a violation actually occurred. (ii) Complainant means any individual, or their authorized representative, who files a complaint as defined in paragraph (a)(2)(i) of this section. (b) Complaints process. (1) DOL will consider the date a complaint is filed to be the date upon which DOL receives an oral or written statement that identifies information about the complaint sufficient to identify the parties involved and the action or inaction complained of. (2) DOL will notify complainants, by oral or written means, of receipt of the complaint no later than 60 business days after the complaint is received. DOL will include a response acknowledging receipt of the complaint, notifying the complainant of their rights and obligations under the complaints process, and describing the next steps of the complaint resolution process. As part of the response, DOL may request additional information needed to process the complaint. Such additional information may include: (i) Explanations of benefits; (ii) Processed claims; (iii) Information about the health care provider, facility, or provider of air ambulance services involved; (iv) Information about the group health plan or health insurance issuer covering the individual; (v) Information to support a determination regarding whether the service was an emergency service or non-emergency service; (vi) The summary plan description, policy, certificate, contract of insurance, membership booklet, outline of coverage, or other evi… | ||||
| 29:29:9.1.2.12.16.4.11.8 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.716-8 Independent dispute resolution process. | PBGC | [86 FR 56112, Oct. 7, 2021, as amended at 87 FR 52649, Aug. 26, 2022; 88 FR 88524, Dec. 21, 2023] | (a) Scope and definitions— (1) Scope. This section sets forth requirements with respect to the independent dispute resolution (IDR) process (referred to in this section as the Federal IDR process) under which a nonparticipating provider, nonparticipating emergency facility, or nonparticipating provider of air ambulance services (as applicable), and a group health plan or health insurance issuer offering group health insurance coverage completes a requisite open negotiation period and at least one party submits a notification under paragraph (b) of this section to initiate the Federal IDR process under paragraph (c) of this section, and under which an IDR entity (as certified under paragraph (e) of this section) determines the amount of payment under the plan or coverage for an item or service furnished by the provider or facility. (2) Definitions. Unless otherwise stated, the definitions in § 2590.716-3 of this part apply to this section. Additionally, for purposes of this section, the following definitions apply: (i) Batched items and services means multiple qualified IDR items or services that are considered jointly as part of one payment determination by a certified IDR entity for purposes of the Federal IDR process. In order for a qualified IDR item or service to be included in a batched item or service, the qualified IDR item or service must meet the criteria set forth in paragraph (c)(3) of this section. (ii) Breach means the acquisition, access, use, or disclosure of individually identifiable health information (IIHI) in a manner not permitted under paragraph (e)(2)(v) of this section that compromises the security or privacy of the IIHI. (A) Breach excludes: ( 1 ) Any unintentional acquisition, access, or use of IIHI by personnel, a contractor, or a subcontractor of a certified IDR entity that is acting under the authority of that certified IDR entity, if the acquisition, access, or use was made in good faith and within the scope of that authority and that does not result in further use or di… | |||
| 29:29:9.1.2.12.16.4.11.9 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | D | Subpart D—Surprise Billing and Transparency Requirements | § 2590.717-1 Preventing surprise medical bills for air ambulance services. | PBGC | (a) In general. If a group health plan or a health insurance issuer offering group health insurance coverage provides or covers any benefits for air ambulance services, the plan or issuer must cover such services from a nonparticipating provider of air ambulance services in accordance with paragraph (b) of this section. (b) Coverage requirements. A plan or issuer described in paragraph (a) of this section must provide coverage of air ambulance services in the following manner— (1) The cost-sharing requirements with respect to the services must be the same requirements that would apply if the services were provided by a participating provider of air ambulance services. (2) The cost-sharing requirement must be calculated as if the total amount that would have been charged for the services by a participating provider of air ambulance services were equal to the lesser of the qualifying payment amount (as determined in accordance with § 2590.716-6) or the billed amount for the services. (3) The cost-sharing amounts must be counted towards any in-network deductible and in-network out-of-pocket maximums (including the annual limitation on cost sharing under section 2707(b) of the PHS Act) (as applicable) applied under the plan or coverage (and the in-network deductible and out-of-pocket maximums must be applied) in the same manner as if the cost-sharing payments were made with respect to services furnished by a participating provider of air ambulance services. (4) The plan or issuer must— (i) Not later than 30 calendar days after the bill for the services is transmitted by the provider of air ambulance services, determine whether the services are covered under the plan or coverage and, if the services are covered, send to the provider an initial payment or a notice of denial of payment. For purposes of this paragraph (b)(4)(i), the 30-calendar-day period begins on the date the plan or issuer receives the information necessary to decide a claim for payment for the services. (ii) Pay a total plan or coverage pa… | ||||
| 29:29:9.1.2.12.16.5.11.1 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart E—General Provisions Related to Subparts B and C | § 2590.731 Preemption; State flexibility; construction. | PBGC | [69 FR 78778, Dec. 30, 2004; 70 FR 21147, Apr. 25, 2005; 79 FR 10312, Feb. 24, 2014] | (a) Continued applicability of State law with respect to health insurance issuers. Subject to paragraph (b) of this section and except as provided in paragraph (c) of this section, part 7 of subtitle B of Title I of the Act is not to 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. (b) Continued preemption with respect to group health plans. Nothing in part 7 of subtitle B of Title I of the Act affects or modifies the provisions of section 514 of the Act with respect to group health plans. (c) Special rules —(1) In general. Subject to paragraph (c)(2) of this section, the provisions of part 7 of subtitle B of Title I of the Act 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 701 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 requires special enrollment periods in addition to those required under section 701(f) of the Act. (d) Definitions —(1) State law. For purposes of this section 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 is treated as a State law rather than a law of the United States. (2) State. For purposes of this section the term State includes a State (as defined in § 2590.… | |||
| 29:29:9.1.2.12.16.5.11.2 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart E—General Provisions Related to Subparts B and C | § 2590.732 Special rules relating to group health plans. | PBGC | [69 FR 78778, Dec. 30, 2004, as amended at 74 FR 51687, Oct. 7, 2009; 79 FR 10312, Feb. 24, 2014; 79 FR 59136, Oct. 1, 2014; 80 FR 14005, Mar. 18, 2015; 81 FR 75325, Oct. 31, 2016; 84 FR 29013, June 20, 2019; 89 FR 23415, Apr. 3, 2024] | (a) Group health plan —(1) Defined. A group health plan means an employee welfare benefit plan to the extent that the plan provides medical care (including items and services paid for as medical care) to employees (including both current and former employees) or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. (2) Determination of number of plans. [Reserved] (b) General exception for certain small group health plans. (1) Subject to paragraph (b)(2) of this section, the requirements of this part do not apply to any group health plan (and group health insurance coverage) for any plan year, if on the first day of the plan year, the plan has fewer than two participants who are current employees. (2) The following requirements apply without regard to paragraph (b)(1) of this section: (i) Section 2590.702(b) of this part, as such section applies with respect to genetic information as a health factor. (ii) Section 2590.702(c) of this part, as such section applies with respect to genetic information as a health factor. (iii) Section 2590.702(e) of this part, as such section applies with respect to genetic information as a health factor. (iv) Section 2590.702-1(b) of this part. (v) Section 2590.702-1(c) of this part. (vi) Section 2590.702-1(d) of this part. (vii) Section 2590.702-1(e) of this part. (viii) Section 2590.711 of this part. (c) Excepted benefits —(1) In general. The requirements of this part do not apply to any group health plan (or any group health insurance coverage) in relation to its provision of the benefits described in paragraph (c)(2), (3), (4), or (5) of this section (or any combination of these benefits). (2) Benefits excepted in all circumstances. The following benefits are excepted in all circumstances— (i) Coverage only for accident (including accidental death and dismemberment); (ii) Disability income coverage; (iii) Liability insurance, including general liability insurance and automobile liability i… | |||
| 29:29:9.1.2.12.16.5.11.3 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart E—General Provisions Related to Subparts B and C | § 2590.734 Enforcement. [Reserved] | PBGC | |||||
| 29:29:9.1.2.12.16.5.11.4 | 29 | Labor | XXV | L | 2590 | PART 2590—RULES AND REGULATIONS FOR GROUP HEALTH PLANS | B | Subpart E—General Provisions Related to Subparts B and C | § 2590.736 Applicability dates. | PBGC | [89 FR 23416, Apr. 3, 2024] | Sections 2590.701-1 through 2590.701-8 and 2590.731 through 2590.736 are applicable for plan years beginning on or after July 1, 2005. Notwithstanding the previous sentence, for short-term, limited-duration insurance sold or issued on or after September 1, 2024, the definition of short-term, limited-duration insurance in § 2590.701-2 applies for coverage periods beginning on or after September 1, 2024. For short-term, limited-duration insurance sold or issued before September 1, 2024 (including any subsequent renewal or extension consistent with applicable law), the definition of short-term, limited-duration insurance in 29 CFR 2590.701-2, revised as of July 1, 2023, continues to apply, except that paragraph (1)(ii) of the definition of short-term, limited-duration insurance in § 2590.701-2 applies for coverage periods beginning on or after September 1, 2024. |
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CREATE TABLE cfr_sections (
section_id TEXT PRIMARY KEY,
title_number INTEGER,
title_name TEXT,
chapter TEXT,
subchapter TEXT,
part_number TEXT,
part_name TEXT,
subpart TEXT,
subpart_name TEXT,
section_number TEXT,
section_heading TEXT,
agency TEXT,
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source_citation TEXT,
amendment_citations TEXT,
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CREATE INDEX idx_cfr_agency ON cfr_sections(agency);