r/title-26-INTERNAL-REVENUE-CODE wiki — defined terms

“matching payment period” applies in that section

The term “matching payment period” means the period beginning with the beginning of the calendar year in which a general election for the office of President of the United States will be held and ending on the date on which the national convention of the party whose nomination a candidate seeks nominates its candidate for the office of President of the United States, or, in the case of a party which does not make such nomination by national convention, ending on the earlier of (A) the date such party nominates its candidate for the office of President of the United States, or (B) the last day of the last national convention held by a major party during such calendar year.;

“political committee” applies in that section

The term “political committee” means any individual, committee, association, or organization (whether or not incorporated) which accepts contributions or incurs qualified campaign expenses for the purpose of influencing, or attempting to influence, the nomination of any person for election to the office of President of the United States.;

“primary election” applies in that section

The term “primary election” means an election, including a runoff election or a nominating convention or caucus held by a political party, for the selection of delegates to a national nominating convention of a political party, or for the expression of a preference for the nomination of persons for election to the office of President of the United States.;

“qualified campaign expense” applies in that section

The term “qualified campaign expense” means a purchase, payment, distribution, loan, advance, deposit, or gift of money or of anything of value— (A) incurred by a candidate, or by his authorized committee, in connection with his campaign for nomination for election, and (B) neither the incurring nor payment of which constitutes a violation of any law of the United States or of the State in which the expense is incurred or paid.

“State” applies in that section

The term “State” means each State of the United States and the District of Columbia.

“contribution” applies in that section

the term “contribution” means a gift of money made by a written instrument which identifies the person making the contribution by full name and mailing address, but does not include a subscription, loan, advance, or deposit of money, or anything of value or anything described in subparagraph (B), (C), or (D) of section 9032(4). (b) Limitations The total amount of payments to which a candidate is entitled under subsection (a) shall not exceed 50 percent of the expenditure limitation applicable under section 315(b)(1)(A) of the Federal Election Campaign Act of 1971.

“immediate family” applies in that section

the term “immediate family” means a candidate’s spouse, and any child, parent, grandparent, brother, half-brother, sister, or half-sister of the candidate, and the spouses of such persons.

“rule or regulation” applies in that section

the term “rule or regulation” means a provision or series of interrelated provisions stating a single separable rule of law.

“covered motor vehicle safety penalty collections” applies in that section

the term “covered motor vehicle safety penalty collections” means any amount collected in connection with a civil penalty under section 30165 of title 49 , United States Code, reduced by any award authorized by the Secretary of Transportation to be paid to any person in connection with information provided by such person related to a violation of chapter 301 of such title which is a predicate to such civil penalty. (6) Limitation on transfers to Highway Trust Fund (A) In general Except as provided in subparagraph (B), no amount may be appropriated to the Highway Trust Fund on and after the date of any expenditure from the Highway Trust Fund which is not permitted by this section.

“Highway Account” applies in that section

the term “Highway Account” means the portion of the Highway Trust Fund which is not the Mass Transit Account. (f) Determination of Trust Fund balances after September 30, 1998 (1) In general For purposes of determining the balances of the Highway Trust Fund and the Mass Transit Account after September 30, 1998 , the opening balance of the Highway Trust Fund (other than the Mass Transit Account) on October 1, 1998 , shall be $8,000,000,000. The Secretary shall cancel obligations held by the Highway Trust Fund to reflect the reduction in the balance under this paragraph.

“mass transit portion” applies in that section

the term “mass transit portion” means, for any fuel with respect to which tax was imposed under section 4041 or 4081 and otherwise deposited into the Highway Trust Fund, the amount determined at the rate of— (A) except as otherwise provided in this sentence, 2.86 cents per gallon, (B) 1.43 cents per gallon in the case of any partially exempt methanol or ethanol fuel (as defined in section 4041(m)) none of the alcohol in which consists of ethanol, (C) 1.86 cents per energy equivalent of a gallon of diesel (as defined in section 4041(a)(2)(D)) in the case of liquefied natural gas, (D) 2.13 cents per energy equivalent of a gallon of gasoline (as defined in section 4041(a)(2)(C)) in the case of …

“motorboat fuel taxes” applies in that section

the term “motorboat fuel taxes” means the taxes under section 4041(a)(2) with respect to special motor fuels used as fuel in motorboats and under section 4081 with respect to gasoline used as fuel in motorboats, but only to the extent such taxes are deposited into the Highway Trust Fund.

“net highway receipts” applies in that section

The term “net highway receipts” means, with respect to any period, the excess of— (i) the receipts (including interest) of the Highway Trust Fund during such period, over (ii) the amounts to be transferred during such period from such Fund under subsection (c) (other than paragraph (1) thereof).

“small-engine fuel taxes” applies in that section

the term “small-engine fuel taxes” means the taxes under section 4081 with respect to gasoline used as a fuel in the nonbusiness use of small-engine outdoor power equipment, but only to the extent such taxes are deposited into the Highway Trust Fund.

“unfunded highway authorizations” applies in that section

The term “unfunded highway authorizations” means, at any time, the excess (if any) of— (i) the total potential unpaid commitments at such time as a result of the apportionment to the States of the amounts authorized to be appropriated from the Highway Trust Fund, over (ii) the amount available in the Highway Trust Fund at such time to defray such commitments (after all other unpaid commitments at such time which are payable from the Highway Trust Fund have been defrayed). (B) Net highway receipts

“net revenues” applies in that section

the term “net revenues” means the amount estimated by the Secretary based on the excess of— (A) the taxes received in the Treasury under section 4131 (relating to tax on certain vaccines), over (B) the decrease in the tax imposed by chapter 1 resulting from the tax imposed by section 4131. (3) Limitation on transfers to Vaccine Injury Compensation Trust Fund No amount may be appropriated to the Vaccine Injury Compensation Trust Fund on and after the date of any expenditure from the Trust Fund which is not permitted by this section.

“applicable amount” applies throughout its chapter

the term “applicable amount” means— (A) for fiscal year 2020, $275,500,000; (B) for fiscal year 2021, $285,000,000; (C) for fiscal year 2022, $293,500,000; (D) for fiscal year 2023, $311,500,000; (E) for fiscal year 2024, $320,000,000; (F) for fiscal year 2025, $338,000,000; (G) for fiscal year 2026, $355,500,000; (H) for fiscal year 2027, $363,500,000; (I) for fiscal year 2028, $381,000,000; and (J) for fiscal year 2029, $399,000,000. (c) Trustee The Secretary of the Treasury shall be a trustee of the PCORTF.

“net revenues” applies in that section

the term “net revenues” means the amount estimated by the Secretary of the Treasury based on the excess of— (1) the fees received in the Treasury under subchapter B of chapter 34, over (2) the decrease in the tax imposed by chapter 1 resulting from the fees imposed by such subchapter. (f) Termination No amounts shall be available for expenditure from the PCORTF after September 30, 2029 , and any amounts in such Trust Fund after such date shall be transferred to the general fund of the Treasury.

“1950 UMWA Benefit Plan” applies throughout its chapter

The term “1950 UMWA Benefit Plan” means a UMWA Benefit Plan, participation in which is substantially limited to individuals who retired before 1976. (C) 1974 UMWA Benefit Plan

“1950 UMWA Pension Plan” applies throughout its chapter

The term “1950 UMWA Pension Plan” means a pension plan described in section 404(c) (or a continuation thereof), participation in which is substantially limited to individuals who retired before 1976. (3) 1974 UMWA Pension Plan

“1974 UMWA Benefit Plan” applies throughout its chapter

The term “1974 UMWA Benefit Plan” means a UMWA Benefit Plan, participation in which is substantially limited to individuals who retired on or after January 1, 1976 . (2) 1950 UMWA Pension Plan

“1974 UMWA Pension Plan” applies throughout its chapter

The term “1974 UMWA Pension Plan” means a pension plan described in section 404(c) (or a continuation thereof), participation in which is substantially limited to individuals who retired in 1976 and thereafter. (4) 1992 UMWA Benefit Plan

“1988 agreement operator” applies in that section

The term “1988 agreement operator” means— (A) a signatory operator which was a signatory to the 1988 National Bituminous Coal Wage Agreement, (B) an employer in the coal industry which was a signatory to an agreement containing pension and health care contribution and benefit provisions which are the same as those contained in the 1988 National Bituminous Coal Wage Agreement, or (C) an employer from which contributions were actually received after 1987 and before July 20, 1992 , by the 1950 UMWA Benefit Plan or the 1974 UMWA Benefit Plan in connection with employment in the coal industry during the period covered by the 1988 National Bituminous Coal Wage Agreement.

“1992 UMWA Benefit Plan” applies throughout its chapter

The term “1992 UMWA Benefit Plan” means the plan referred to in section 9712. (5) Combined Fund

“assigned operator” applies in that section

The term “assigned operator” means, with respect to an eligible beneficiary defined in section 9703(f), the signatory operator to which liability under subchapter B with respect to the beneficiary is assigned under section 9706. (6) Operators of dependent beneficiaries For purposes of this chapter, the signatory operator, last signatory operator, or assigned operator of any eligible beneficiary under this chapter who is a coal industry retiree shall be considered to be the signatory operator, last signatory operator, or assigned operator with respect to any other individual who is an eligible beneficiary under this chapter by reason of a relationship to the retiree.

“coal wage agreement” applies in that section

The term “coal wage agreement” means— (A) the National Bituminous Coal Wage Agreement, or (B) any other agreement entered into between an employer in the coal industry and the United Mine Workers of America that required or requires one or both of the following: (i) the provision of health benefits to retirees of such employer, eligibility for which is based on years of service credited under a plan established by the settlors and described in section 404(c) or a continuation of such plan; or (ii) contributions to the 1950 UMWA Benefit Plan or the 1974 UMWA Benefit Plan, or any predecessor thereof. (2) Settlors

“Combined Fund” applies throughout its chapter

The term “Combined Fund” means the United Mine Workers of America Combined Benefit Fund established under section 9702. (b) Agreements For purposes of this section— (1) Coal wage agreement

“eligible seller” applies in that section

the term “eligible seller” means an assigned operator described in section 9704(j)(2) or a related person to such assigned operator. (d) Enactment date For purposes of this chapter,

“enactment date” applies throughout its chapter

the term “enactment date” means the date of the enactment of this chapter.

“last signatory operator” applies in that section

The term “last signatory operator” means, with respect to a coal industry retiree, a signatory operator which was the most recent coal industry employer of such retiree. (5) Assigned operator

“National Bituminous Coal Wage Agreement” applies throughout its chapter

The term “National Bituminous Coal Wage Agreement” means a collective bargaining agreement negotiated by the BCOA and the United Mine Workers of America. (c) Terms relating to operators For purposes of this section— (1) Signatory operator

“settlors” applies in that section

The term “settlors” means the United Mine Workers of America and the Bituminous Coal Operators’ Association, Inc. (referred to in this chapter as the “BCOA”). (3) National Bituminous Coal Wage Agreement

“signatory operator” applies in that section

The term “signatory operator” means a person which is or was a signatory to a coal wage agreement. (2) Related persons (A) In general A person shall be considered to be a related person to a signatory operator if that person is— (i) a member of the controlled group of corporations (within the meaning of section 52(a)) which includes such signatory operator; (ii) a trade or business which is under common control (as determined under section 52(b)) with such signatory operator; or (iii) any other person who is identified as having a partnership interest or joint venture with a signatory operator in a business within the coal industry, but only if such business employed eligible beneficiaries, …

“UMWA Benefit Plan” applies throughout its chapter

The term “UMWA Benefit Plan” means a plan— (i) which is described in section 404(c), or a continuation thereof; and (ii) which provides health benefits to retirees and beneficiaries of the industry which maintained the 1950 UMWA Pension Plan. (B) 1950 UMWA Benefit Plan

“unrelated person” applies throughout its chapter

The term “unrelated person” means a purchaser who does not bear a relationship to the eligible seller described in section 267(b). (C) Eligible seller For purposes of this paragraph,

“eligible beneficiary” applies throughout its subchapter

the term “eligible beneficiary” means an individual who— (1) is a coal industry retiree who, on July 20, 1992 , was eligible to receive, and receiving, benefits from the 1950 UMWA Benefit Plan or the 1974 UMWA Benefit Plan, or (2) on such date was eligible to receive, and receiving, benefits in either such plan by reason of a relationship to such retiree.

“applicable percentage” applies in that section

The term “applicable percentage” means, with respect to any assigned operator, the percentage determined by dividing the number of eligible beneficiaries assigned under section 9706 to such operator by the total number of eligible beneficiaries assigned under section 9706 to all such operators (determined on the basis of assignments as of October 1, 1993 ).

“controlled group of corporations” applies in that section

the term “controlled group of corporations” has the meaning given such term by section 52(a). (3) Requirements A payment meets the requirements of this paragraph if— (A) the amount of the payment is not less than the present value of the total premium liability under this chapter with respect to the Combined Fund of the assigned operators or related persons described in paragraph (1) or their assignees, as determined by the operator’s or related person’s enrolled actuary (as defined in section 7701(a)(35)) using actuarial methods and assumptions each of which is reasonable and which are reasonable in the aggregate, as determined by such enrolled actuary; (B) such enrolled actuary files with …

“noncompliance period” applies in that section

the term “noncompliance period” means, with respect to any failure to pay any premium or installment thereof, the period— (1) beginning on the due date for such premium or installment, and (2) ending on the date of payment of such premium or installment. (d) Limitations on amount of penalty (1) In general No penalty shall be imposed by subsection (a) on any failure during any period for which it is established to the satisfaction of the Secretary of the Treasury that none of the persons responsible for such failure knew, or exercising reasonable diligence would have known, that such failure existed.

“eligible beneficiary” applies in that section

the term “eligible beneficiary” means any individual who is eligible for health benefits under a plan described in subsection (a) or (b) by reason of the individual’s relationship with the retiree described in such subsection (or to an individual who, based on service and employment history at the time of death, would have been so described but for such death). (g) Rules applicable to this part and part II For purposes of this part and part II— (1) Successor

“last signatory operator” applies throughout its part

The term “last signatory operator” shall include a successor in interest of such operator. (2) Reassignment upon purchase If a person becomes a successor of a last signatory operator after the enactment date, the last signatory operator may transfer any liability of such operator under this chapter with respect to an eligible beneficiary to such successor, and such successor shall be treated as the last signatory operator with respect to such eligible beneficiary for purposes of this chapter.

“1988 last signatory operator” applies in that section

the term “1988 last signatory operator” means a last signatory operator which is a 1988 agreement operator.

“eligible beneficiary” applies in that section

the term “eligible beneficiary” means an individual who— (A) but for the enactment of this chapter, would be eligible to receive benefits from the 1950 UMWA Benefit Plan or the 1974 UMWA Benefit Plan, based upon age and service earned as of February 1, 1993 ; or (B) with respect to whom coverage is required to be provided under section 9711, but who does not receive such coverage from the applicable last signatory operator or any related person, and any individual who is eligible for benefits by reason of a relationship to an individual described in subparagraph (A) or (B).

“affiliation period” applies in that section

the term “affiliation period” means a period which, under the terms of the health insurance coverage offered by the health maintenance organization, must expire before the health insurance coverage becomes effective. During such an affiliation period, the organization is not required to provide health care services or benefits and no premium shall be charged to the participant or beneficiary. (ii) Beginning Such period shall begin on the enrollment date. (iii) Runs concurrently with waiting periods Any such affiliation period shall run concurrently with any waiting period under the plan.

“creditable coverage” applies in that section

the term “creditable coverage” means, with respect to an individual, coverage of the individual under any of the following: (A) A group health plan. (B) Health insurance coverage. (C) Part A or part B of title XVIII of the Social Security Act. (D) Title XIX of the Social Security Act, other than coverage consisting solely of benefits under section 1928. (E) Chapter 55 of title 10, United States Code. (F) A medical care program of the Indian Health Service or of a tribal organization. (G) A State health benefits risk pool. (H) A health plan offered under chapter 89 of title 5, United States Code. (I) A public health plan (as defined in regulations).

“enrollment date” applies in that section

The term “enrollment date” means, with respect to an individual covered under a group health plan, the date of enrollment of the individual in the plan or, if earlier, the first day of the waiting period for such enrollment. (3) Late enrollee

“late enrollee” applies in that section

The term “late enrollee” means, with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during— (A) the first period in which the individual is eligible to enroll under the plan, or (B) a special enrollment period under subsection (f). (4) Waiting period

“preexisting condition exclusion” applies in that section

The term “preexisting condition exclusion” means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date. (B) Treatment of genetic information For purposes of this section, genetic information shall not be treated as a condition described in subsection (a)(1) in the absence of a diagnosis of the condition related to such information. (2) Enrollment date

“TAA-eligible individual” applies in that section

The terms “TAA-eligible individual” and “TAA-related loss of coverage” have the meanings given such terms in section 4980B(f)(5)(C)(iv). (3) Method of crediting coverage (A) Standard method Except as otherwise provided under subparagraph (B), for purposes of applying subsection (a)(3), a group health plan shall count a period of creditable coverage without regard to the specific benefits for which coverage is offered during the period. (B) Election of alternative method A group health plan may elect to apply subsection (a)(3) based on coverage of any benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subparagraph (A).

“TAA-related loss of coverage” applies in that section

The terms “TAA-eligible individual” and “TAA-related loss of coverage” have the meanings given such terms in section 4980B(f)(5)(C)(iv). (3) Method of crediting coverage (A) Standard method Except as otherwise provided under subparagraph (B), for purposes of applying subsection (a)(3), a group health plan shall count a period of creditable coverage without regard to the specific benefits for which coverage is offered during the period. (B) Election of alternative method A group health plan may elect to apply subsection (a)(3) based on coverage of any benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subparagraph (A).

“waiting period” applies in that section

The term “waiting period” means, with respect to a group health plan and an individual who is a potential participant or beneficiary in the plan, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan. (c) Rules relating to crediting previous coverage (1) Creditable coverage defined For purposes of this part,

“multiple employer welfare arrangement” applies in that section

the term “multiple employer welfare arrangement” has the meaning given such term by section 3(40) of the Employee Retirement Income Security Act of 1974, as in effect on the date of the enactment of this section.

“aggregate lifetime limit” applies in that section

The term “aggregate lifetime limit” means, with respect to benefits under a group health plan, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan with respect to an individual or other coverage unit. (2) Annual limit

“annual limit” applies in that section

The term “annual limit” means, with respect to benefits under a group health plan, a dollar limitation on the total amount of benefits that may be paid with respect to such benefits in a 12-month period under the plan with respect to an individual or other coverage unit. (3) Medical or surgical benefits

“financial requirement” applies in that section

The term “financial requirement” includes deductibles, copayments, coinsurance, and out-of-pocket expenses, but excludes an aggregate lifetime limit and an annual limit subject to paragraphs (1) and (2). (ii) Predominant A financial requirement or treatment limit is considered to be predominant if it is the most common or frequent of such type of limit or requirement. (iii) Treatment limitation

“medical or surgical benefits” applies in that section

The term “medical or surgical benefits” means benefits with respect to medical or surgical services, as defined under the terms of the plan, but does not include mental health or substance use disorder benefits. (4) Mental health benefits

“mental health benefits” applies in that section

The term “mental health benefits” means benefits with respect to services for mental health conditions, as defined under the terms of the plan and in accordance with applicable Federal and State law. (5) Substance use disorder benefits

“small employer” applies in that section

the term “small employer” means, with respect to a calendar year and a plan year, an employer who employed an average of at least 2 (or 1 in the case of an employer residing in a State that permits small groups to include a single individual) but not more than 50 employees on business days during the preceding calendar year. For purposes of the preceding sentence, all persons treated as a single employer under subsection (b), (c), (m), or ( o ) of section 414 shall be treated as 1 employer and rules similar to rules of subparagraphs (B) and (C) of section 4980D(d)(2) shall apply.

“substance use disorder benefits” applies in that section

The term “substance use disorder benefits” means benefits with respect to services for substance use disorders, as defined under the terms of the plan and in accordance with applicable Federal and State law.

“treatment limitation” applies in that section

The term “treatment limitation” includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment. (4) Availability of plan information The criteria for medical necessity determinations made under the plan with respect to mental health or substance use disorder benefits shall be made available by the plan administrator in accordance with regulations to any current or potential participant, beneficiary, or contracting provider upon request.

“medically necessary leave of absence” applies in that section

the term “medically necessary leave of absence” means, with respect to a dependent child described in subsection (b)(2) in connection with a group health plan, a leave of absence of such child from a postsecondary educational institution (including an institution of higher education as defined in section 102 of the Higher Education Act of 1965), or any other change in enrollment of such child at such an institution, that— (1) commences while such child is suffering from a serious illness or injury; (2) is medically necessary; and (3) causes such child to lose student status for purposes of coverage under the terms of the plan or coverage.

“cost-sharing” applies in that section

The term “cost-sharing” includes copayments, coinsurance, and deductibles. (b) Coverage of non-emergency services performed by nonparticipating providers at certain participating facilities (1) In general In the case of items or services (other than emergency services to which subsection (a) applies) for which any benefits are provided or covered by a group health plan furnished to a participant or beneficiary of such plan by a nonparticipating provider (as defined in subsection (a)(3)(G)(i)) (and who, with respect to such items and services, has not satisfied the notice and consent criteria of section 2799B–2(d) of the Public Health Service Act) with respect to a visit (as defined by the …

“emergency department of a hospital” applies throughout its subchapter

The term “emergency department of a hospital” includes a hospital outpatient department that provides emergency services (as defined in subparagraph (C)(i)). (B) Emergency medical condition

“emergency medical condition” applies throughout its subchapter

The term “emergency medical condition” means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act.

“emergency services” applies in that section

the term “emergency services” shall include, unless each of the conditions described in subclause (II) are met, in addition to the items and services described in clause (i), items and services— (aa) for which benefits are provided or covered under the plan; and (bb) that are furnished by a nonparticipating provider or nonparticipating emergency facility (regardless of the department of the hospital in which such items or services are furnished) after the participant or beneficiary is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in clause (i) are furnished.

“first coverage year” applies in that section

The term “first coverage year” means, with respect to a group health plan and an item or service for which coverage is not offered in 2019 under such plan or coverage, the first year after 2019 for which coverage for such item or service is offered under such plan. (II) First sufficient information year

“first sufficient information year” applies in that section

The term “first sufficient information year” means, with respect to a group health plan— (aa) in the case of an item or service for which the plan does not have sufficient information to calculate the median of the contracted rates described in clause (i)(I) in 2019, the first year subsequent to 2022 for which such sponsor has such sufficient information to calculate the median of such contracted rates in the year previous to such first subsequent year; and (bb) in the case of a newly covered item or service, the first year subsequent to the first coverage year for such item or service with respect to such plan for which the sponsor has sufficient information to calculate the median of the …

“independent freestanding emergency department” applies in that section

The term “independent freestanding emergency department” means a health care facility that— (i) is geographically separate and distinct and licensed separately from a hospital under applicable State law; and (ii) provides any of the emergency services (as defined in subparagraph (C)(i)). (E) Qualifying payment amount (i) In general

“newly covered item or service” applies in that section

The term “newly covered item or service” means, with respect to a group health plan, an item or service for which coverage was not offered in 2019 under such plan or coverage, but is offered under such plan or coverage in a year after 2019. (F) Nonparticipating emergency facility; participating emergency facility (i) Nonparticipating emergency facility

“nonparticipating emergency facility” applies in that section

The term “nonparticipating emergency facility” means, with respect to an item or service and a group health plan, an emergency department of a hospital, or an independent freestanding emergency department, that does not have a contractual relationship directly or indirectly with the plan for furnishing such item or service under the plan. (ii) Participating emergency facility

“nonparticipating provider” applies in that section

The term “nonparticipating provider” means, with respect to an item or service and a group health plan, a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law and who does not have a contractual relationship with the plan or issuer, respectively, for furnishing such item or service under the plan. (ii) Participating provider

“out-of-network rate” applies in that section

The term “out-of-network rate” means, with respect to an item or service furnished in a State during a year to a participant or beneficiary of a group health plan receiving such item or service from a nonparticipating provider or nonparticipating emergency facility— (i) subject to clause (iii), in the case of such item or service furnished in a State that has in effect a specified State law with respect to such plan; such a nonparticipating provider or nonparticipating emergency facility; and such an item or service, the amount determined in accordance with such law; (ii) subject to clause (iii), in the case such State does not have in effect such a law with respect to such item or service, …

“participating emergency facility” applies in that section

The term “participating emergency facility” means, with respect to an item or service and a group health plan, an emergency department of a hospital, or an independent freestanding emergency department, that has a contractual relationship directly or indirectly with the plan, with respect to the furnishing of such an item or service at such facility. (G) Nonparticipating providers; participating providers (i) Nonparticipating provider

“participating health care facility” applies in that section

The term “participating health care facility” means, with respect to an item or service and a group health plan, a health care facility described in clause (ii) that has a direct or indirect contractual relationship with the plan, with respect to the furnishing of such an item or service at the facility. (ii) Health care facility described A health care facility described in this clause, with respect to a group health plan or health insurance coverage offered in the group or individual market, is each of the following: (I) A hospital (as defined in 1861(e) of the Social Security Act). (II) A hospital outpatient department.

“participating provider” applies in that section

The term “participating provider” means, with respect to an item or service and a group health plan, a physician or other health care provider who is acting within the scope of practice of that provider’s license or certification under applicable State law and who has a contractual relationship with the plan for furnishing such item or service under the plan. (H) Recognized amount

“qualifying payment amount” applies in that section

The term “qualifying payment amount” means, subject to clauses (ii) and (iii), with respect to a sponsor of a group health plan— (I) for an item or service furnished during 2022, the median of the contracted rates recognized by the plan (determined with respect to all such plans of such sponsor that are offered within the same insurance market (specified in subclause (I), (II), or (III) of clause (iv)) as the plan) as the total maximum payment (including the cost-sharing amount imposed for such item or service and the amount to be paid by the plan) under such plans on January 31, 2019 for the same or a similar item or service that is provided by a provider in the same or similar specialty …

“recognized amount” applies in that section

The term “recognized amount” means, with respect to an item or service furnished by a nonparticipating provider or nonparticipating emergency facility during a year and a group health plan— (i) subject to clause (iii), in the case of such item or service furnished in a State that has in effect a specified State law with respect to such plan; such a nonparticipating provider or nonparticipating emergency facility; and such an item or service, the amount determined in accordance with such law; (ii) subject to clause (iii), in the case of such item or service furnished in a State that does not have in effect a specified State law, with respect to such plan; such a nonparticipating provider or …

“specified item or service” applies in that section

the term “specified item or service” means an item or service that has low utilization or significant variation in costs (such as when furnished as part of a complex treatment), as specified by the Secretary.

“specified State law” applies in that section

The term “specified State law” means, with respect to a State, an item or service furnished by a nonparticipating provider or nonparticipating emergency facility during a year and a group health plan, a State law that provides for a method for determining the total amount payable under such a plan (to the extent such State law applies to such plan, subject to section 514 1 ) in the case of a participant or beneficiary covered under such plan and receiving such item or service from such a nonparticipating provider or nonparticipating emergency facility.

“air ambulance service” applies in that section

The term “air ambulance service” means medical transport by helicopter or airplane for patients. (2) Qualifying payment amount

“nonparticipating provider” applies in that section

The term “nonparticipating provider” has the meaning given such term in section 9816(a)(3).

“qualifying payment amount” applies in that section

The term “qualifying payment amount” has the meaning given such term in section 9816(a)(3). (3) Nonparticipting provider

“continuing care patient” applies in that section

The term “continuing care patient” means an individual who, with respect to a provider or facility— (A) is undergoing a course of treatment for a serious and complex condition from the provider or facility; (B) is undergoing a course of institutional or inpatient care from the provider or facility; (C) is scheduled to undergo nonelective surgery from the provider or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery; (D) is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or (E) is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security …

“serious and complex condition” applies in that section

The term “serious and complex condition” means, with respect to a participant or beneficiary under a group health plan— (A) in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or (B) in the case of a chronic illness or condition, a condition that— (i) is life-threatening, degenerative, potentially disabling, or congenital; and (ii) requires specialized medical care over a prolonged period of time. (3) Terminated

“terminated” applies in that section

The term “terminated” includes, with respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract for failure to meet applicable quality standards or for fraud.

“provider directory information” applies in that section

the term “provider directory information” includes, with respect to a group health plan, the name, address, specialty, telephone number, and digital contact information of each health care provider or health care facility with which such plan has a contractual relationship for furnishing items and services under such plan. (7) Rule of construction Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories.

“applicable entity” applies in that section

The term “applicable entity” means— (A) an applicable group purchasing organization, drug manufacturer, distributor, wholesaler, rebate aggregator (or other purchasing entity designed to aggregate rebates), or associated third party; (B) any subsidiary, parent, affiliate, or subcontractor of a group health plan, health insurance issuer, entity that provides pharmacy benefit management services on behalf of such a plan or issuer, or any entity described in subparagraph (A); or (C) such other entity as the Secretary may specify through rulemaking. (2) Applicable group purchasing organization

“applicable group purchasing organization” applies in that section

The term “applicable group purchasing organization” means a group purchasing organization that is affiliated with or under common ownership with an entity providing pharmacy benefit management services. (3) Contracted compensation

“contracted compensation” applies in that section

The term “contracted compensation” means the sum of any ingredient cost and dispensing fee for a drug (inclusive of the out-of-pocket costs to the participant or beneficiary), or another analogous compensation structure that the Secretary may specify through regulations. (4) Gross spending The term “gross spending”, with respect to prescription drug benefits under a group health plan, means the amount spent by a group health plan on prescription drug benefits, calculated before the application of rebates, fees, alternative discounts, or other remuneration.

“plan sponsor” applies in that section

The term “plan sponsor” has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1002(16)(B) ). (7) Remuneration

“remuneration” applies in that section

The term “remuneration” has the meaning given such term by the Secretary, through rulemaking, which shall be reevaluated by the Secretary every 5 years. (8) Specified large employer

“specified large employer” applies in that section

The term “specified large employer” means, in connection with a group health plan established or maintained by a single employer, with respect to a calendar year or a plan year, as applicable, an employer who employed an average of at least 100 employees on business days during the preceding calendar year or plan year and who employs at least 1 employee on the first day of the calendar year or plan year. (9) Specified large plan

“specified large plan” applies in that section

The term “specified large plan” means a group health plan established or maintained by a plan sponsor described in clause (ii) or (iii) of section 3(16)(B) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1002(16)(B) ) that had an average of at least 100 participants on business days during the preceding calendar year or plan year, as applicable. (10) Wholesale acquisition cost

“wholesale acquisition cost” applies in that section

The term “wholesale acquisition cost” has the meaning given such term in section 1847A(c)(6)(B) of the Social Security Act ( 42 U.S.C. 1395w–3a(c)(6)(B) ).

“eligible employee” applies in that section

The term “eligible employee” means any employee of an eligible employer, except that the terms of the arrangement may exclude from consideration employees described in any clause of section 105(h)(3)(B) (applied by substituting “90 days” for “3 years” in clause (i) thereof). (B) Eligible employer

“eligible employer” applies in that section

The term “eligible employer” means an employer that— (i) is not an applicable large employer as defined in section 4980H(c)(2), and (ii) does not offer a group health plan to any of its employees. (C) Permitted benefit

“permitted benefit” applies in that section

The term “permitted benefit” means, with respect to any eligible employee, the maximum dollar amount of payments and reimbursements which may be made under the terms of the qualified small employer health reimbursement arrangement for the year with respect to such employee.

“qualified small employer health reimbursement arrangement” applies in that section

The term “qualified small employer health reimbursement arrangement” means an arrangement which— (i) is described in subparagraph (B), and (ii) is provided on the same terms to all eligible employees of the eligible employer.

“COBRA continuation provision” applies throughout its chapter

The term “COBRA continuation provision” means any of the following: (A) Section 4980B, other than subsection (f)(1) thereof insofar as it relates to pediatric vaccines. (B) Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1161 et seq.), other than section 609 of such Act. (C) Title XXII of the Public Health Service Act. (2) Governmental plan

“excepted benefits” applies throughout its chapter

the term “excepted benefits” means benefits under one or more (or any combination thereof) of the following: (1) Benefits not subject to requirements (A) Coverage only for accident, or disability income insurance, or any combination thereof. (B) Coverage issued as a supplement to liability insurance. (C) Liability insurance, including general liability insurance and automobile liability insurance. (D) Workers’ compensation or similar insurance. (E) Automobile medical payment insurance. (F) Credit-only insurance. (G) Coverage for on-site medical clinics.

“family member” applies throughout its chapter

The term “family member” means, with respect to any individual— (A) a dependent (as such term is used for purposes of section 9801(f)(2)) of such individual, and (B) any other individual who is a first-degree, second-degree, third-degree, or fourth-degree relative of such individual or of an individual described in subparagraph (A). (7) Genetic information (A) In general

“genetic information” applies throughout its chapter

The term “genetic information” means, with respect to any individual, information about— (i) such individual’s genetic tests, (ii) the genetic tests of family members of such individual, and (iii) the manifestation of a disease or disorder in family members of such individual. (B) Inclusion of genetic services and participation in genetic research Such term includes, with respect to any individual, any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by such individual or any family member of such individual. (C) Exclusions The term “genetic information” shall not include information about the sex or age of any individual.

“genetic services” applies throughout its chapter

The term “genetic services” means— (A) a genetic test; (B) genetic counseling (including obtaining, interpreting, or assessing genetic information); or (C) genetic education. (10) Underwriting purposes

“genetic test” applies throughout its chapter

The term “genetic test” means an analysis of human DNA, RNA, chromosomes, proteins, or metabolites, that detects genotypes, mutations, or chromosomal changes. (B) Exceptions The term “genetic test” does not mean— (i) an analysis of proteins or metabolites that does not detect genotypes, mutations, or chromosomal changes, or (ii) an analysis of proteins or metabolites that is directly related to a manifested disease, disorder, or pathological condition that could reasonably be detected by a health care professional with appropriate training and expertise in the field of medicine involved. (9) Genetic services

“governmental plan” applies throughout its chapter

The term “governmental plan” has the meaning given such term by section 414(d). (3) Medical care

“group health plan” applies throughout its chapter

the term “group health plan” has the meaning given to such term by section 5000(b)(1). (b) Definitions relating to health insurance For purposes of this chapter— (1) Health insurance coverage (A) In general Except as provided in subparagraph (B),

“health insurance coverage” applies throughout its chapter

the term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer. (B) No application to certain excepted benefits In applying subparagraph (A), excepted benefits described in subsection (c)(1) shall not be treated as benefits consisting of medical care. (2) Health insurance issuer

“health insurance issuer” applies throughout its chapter

The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in paragraph (3)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974, as in effect on the date of the enactment of this section). Such term does not include a group health plan. (3) Health maintenance organization

“health maintenance organization” applies throughout its chapter

The term “health maintenance organization” means— (A) a federally qualified health maintenance organization (as defined in section 1301(a) of the Public Health Service Act ( 42 U.S.C. 300e(a) )), (B) an organization recognized under State law as a health maintenance organization, or (C) a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization. (c) Excepted benefits For purposes of this chapter,

“medical care” applies throughout its chapter

The term “medical care” has the meaning given such term by section 213(d) determined without regard to— (A) paragraph (1)(C) thereof, and (B) so much of paragraph (1)(D) thereof as relates to qualified long-term care insurance. (4) Network plan

“network plan” applies throughout its chapter

The term “network plan” means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care are provided, in whole or in part, through a defined set of providers under contract with the issuer. (5) Placed for adoption defined The term “placement”, or being “placed”, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement with such person terminates upon the termination of such legal obligation. (6) Family member

“underwriting purposes” applies throughout its chapter

The term “underwriting purposes” means, with respect to any group health plan, or health insurance coverage offered in connection with a group health plan— (A) rules for, or determination of, eligibility (including enrollment and continued eligibility) for benefits under the plan or coverage; (B) the computation of premium or contribution amounts under the plan or coverage; (C) the application of any pre-existing condition exclusion under the plan or coverage; and (D) other activities related to the creation, renewal, or replacement of a contract of health insurance or health benefits.