r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE wiki — defined terms
The statute’s own glossary: every term Title 42 defines, in section order.
“non-metropolitan area” applies in that section
The term “non-metropolitan area” means an area no part of which is within an area designated as a standard metropolitan statistical area by the Office of Management and Budget and which does not contain a city whose population exceeds fifty thousand individuals.
“supplemental health services” applies in that section
The term “supplemental health services” means any health service which is not included as a basic health service under paragraph (1) of this section. If a health service provided by a physician may also be provided under applicable State law by a dentist, optometrist, podiatrist, psychologist, or other health care personnel, a health maintenance organization may provide such service through an optometrist, dentist, podiatrist, psychologist, or other health care personnel (as the case may be) licensed to provide such service.
“party in interest” applies in that section
the term “party in interest” means: (1) any director, officer, partner, or employee responsible for management or administration of a health maintenance organization, any person who is directly or indirectly the beneficial owner of more than 5 per centum of the equity of the organization, any person who is the beneficial owner of a mortgage, deed of trust, note, or other interest secured by, and valuing more than 5 per centum of the health maintenance organization, and, in the case of a health maintenance organization organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation law; (2) any entity in which a person described in …
“qualified health maintenance organization” applies in that section
the term “qualified health maintenance organization” means (1) a health maintenance organization which has provided assurances satisfactory to the Secretary that it provides basic and supplemental health services to its members in the manner prescribed by section 300e(b) of this title and that it is organized and operated in the manner prescribed by section 300e(c) of this title , and (2) an entity which proposes to become a health maintenance organization and which the Secretary determines will when it becomes operational provide basic and supplemental health services to its members in the manner prescribed by section 300e(b) of this title and will be organized and operated in the manner …
“Administrator” applies in that section
The term “Administrator” means the Administrator of the Environmental Protection Agency.;
“Agency” applies in that section
The term “Agency” means the Environmental Protection Agency.;
“community water system” applies in that section
The term “community water system” means a public water system that— (A) serves at least 15 service connections used by year-round residents of the area served by the system; or (B) regularly serves at least 25 year-round residents. (16) Noncommunity water system .—
“contaminant” applies in that section
The term “contaminant” means any physical, chemical, biological, or radiological substance or matter in water.;
“Council” applies in that section
The term “Council” means the National Drinking Water Advisory Council established under section 300j–5 of this title .;
“Federal agency” applies in that section
The term “Federal agency” means any department, agency, or instrumentality of the United States.;
“Indian Tribe” applies in that section
The term “Indian Tribe” means any Indian tribe having a Federally recognized governing body carrying out substantial governmental duties and powers over any area. For purposes of sections 300j–12, 300j–19a, and 300j–19b of this title, the term includes any Native village (as defined in section 1602(c) of title 43 ). (15) Community water system .—
“maximum contaminant level” applies in that section
The term “maximum contaminant level” means the maximum permissible level of a contaminant in water which is delivered to any user of a public water system. (4) Public water system.— (A) In general .—
“municipality” applies in that section
The term “municipality” means a city, town, or other public body created by or pursuant to State law, or an Indian Tribe.;
“noncommunity water system” applies in that section
The term “noncommunity water system” means a public water system that is not a community water system.
“person” applies in that section
The term “person” means an individual, corporation, company, association, partnership, State, municipality, or Federal agency (and includes officers, employees, and agents of any corporation, company, association, State, municipality, or Federal agency). (13) (A) Except as provided in subparagraph (B),
“primary drinking water regulation” applies throughout its subchapter
The term “primary drinking water regulation” means a regulation which— (A) applies to public water systems; (B) specifies contaminants which, in the judgment of the Administrator, may have any adverse effect on the health of persons; (C) specifies for each such contaminant either— (i) a maximum contaminant level, if, in the judgment of the Administrator, it is economically and technologically feasible to ascertain the level of such contaminant in water in public water systems, or (ii) if, in the judgment of the Administrator, it is not economically or technologically feasible to so ascertain the level of such contaminant, each treatment technique known to the Administrator which leads to a …
“public water system” applies in that section
The term “public water system” means a system for the provision to the public of water for human consumption through pipes or other constructed conveyances, if such system has at least fifteen service connections or regularly serves at least twenty-five individuals. Such term includes (i) any collection, treatment, storage, and distribution facilities under control of the operator of such system and used primarily in connection with such system, and (ii) any collection or pretreatment storage facilities not under such control which are used primarily in connection with such system.
“secondary drinking water regulation” applies in that section
The term “secondary drinking water regulation” means a regulation which applies to public water systems and which specifies the maximum contaminant levels which, in the judgment of the Administrator, are requisite to protect the public welfare. Such regulations may apply to any contaminant in drinking water (A) which may adversely affect the odor or appearance of such water and consequently may cause a substantial number of the persons served by the public water system providing such water to discontinue its use, or (B) which may otherwise adversely affect the public welfare. Such regulations may vary according to geographic and other circumstances.;
“State” applies in that section
the term “State” includes, in addition to the several States, only the District of Columbia, Guam, the Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin Islands, American Samoa, and the Trust Territory of the Pacific Islands. (B) For purposes of section 300j–12 of this title ,
“supplier of water” applies in that section
The term “supplier of water” means any person who owns or operates a public water system.;
“distribution factor” applies in that section
the term “distribution factor” means an amount equal to the living cases of HIV/AIDS (reported to and confirmed by the Director of the Centers for Disease Control and Prevention) in the eligible area involved, as determined under subparagraph (C).
“early intervention services” applies in that section
the term “early intervention services” means HIV/AIDS early intervention services described in section 300ff–51(e) of this title , with follow-up referral provided for the purpose of facilitating the access of individuals receiving the services to HIV-related health services.
“medical outcomes” applies in that section
the term “medical outcomes” means those outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS. (e) Early intervention services (1) In general For purposes of this section,
“support services” applies in that section
the term “support services” means services, subject to the approval of the Secretary, that are needed for individuals with HIV/AIDS to achieve their medical outcomes (such as respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services). (2) Medical outcomes In this subsection,
“eligible area” applies throughout its subpart
The term “eligible area” means a metropolitan area meeting the requirements of section 300ff–11 of this title that are applicable to the area. (2) Metropolitan area
“metropolitan area” applies throughout its subpart
The term “metropolitan area” means an area that is referred to in the HIV/AIDS Surveillance Report of the Centers for Disease Control and Prevention as a metropolitan area, and that has a population of 50,000 or more individuals.
“transitional area” applies in that section
the term “transitional area” means, subject to subsection (c), a metropolitan area for which there has been reported to and confirmed by the Director of the Centers for Disease Control and Prevention a cumulative total of at least 1,000, but fewer than 2,000, cases of AIDS during the most recent period of 5 calendar years for which such data are available.
“early intervention services” applies in that section
the term “early intervention services” means HIV/AIDS early intervention services described in section 300ff–51(e) of this title , with follow-up referral provided for the purpose of facilitating the access of individuals receiving the services to HIV-related health services.
“medical outcomes” applies in that section
the term “medical outcomes” means those outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS. (d) Early intervention services (1) In general For purposes of this section,
“support services” applies in that section
the term “support services” means services, subject to the approval of the Secretary, that are needed for individuals with HIV/AIDS to achieve their medical outcomes (such as respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services). (2) Definition of medical outcomes In this subsection,
“family centered care” applies throughout its subchapter
the term “family centered care” means the system of services described in this section that is targeted specifically to the special needs of infants, children, women, and families. Family centered care shall be based on a partnership between parents, professionals, and the community designed to ensure an integrated, coordinated, culturally sensitive, and community-based continuum of care for children, women, and families with HIV/AIDS.
“home- and community-based health services” applies in that section
the term “home- and community-based health services”— (1) means, with respect to an individual with HIV/AIDS, skilled health services furnished to the individual in the individual’s home pursuant to a written plan of care established by a case management team, that shall include appropriate health care professionals, for the provision of such services and items described in paragraph (2); (2) includes— (A) durable medical equipment; (B) home health aide services and personal care services furnished in the home of the individual; (C) day treatment or other partial hospitalization services; (D) home intravenous and aerosolized drug therapy (including prescription drugs administered as part of …
“HIV-infected patient” applies in that section
The term “HIV-infected patient” means any individual who has been diagnosed to be infected with the human immunodeficiency virus. (3) State
“spouse” applies in that section
The term “spouse” means any individual who is the marriage partner of an HIV-infected patient, or who has been the marriage partner of that patient at any time within the 10-year period prior to the diagnosis of HIV infection. (2) HIV-infected patient
“State” applies in that section
The term “State” means any of the 50 States, the District of Columbia, or any territory of the United States.
“non-ema 1 distribution factor” applies in that section
the term “non-ema 1 distribution factor” means an amount equal to the sum of— (i) the number of living cases of HIV/AIDS in the State involved, as determined under subparagraph (D); less (ii) a number equal to the sum of— (I) the total number of living cases of HIV/AIDS that are within areas in such State that are eligible areas under subpart I of part A for the fiscal year involved, which individual number for an area is the number that applies under section 300ff–11 of this title for the area for such fiscal year; and (II) the total number of such cases that are within areas in such State that are transitional areas under section 300ff–19 of this title for such fiscal year, which …
“State distribution factor” applies in that section
the term “State distribution factor” means an amount equal to the number of living cases of HIV/AIDS in the State involved, as determined under subparagraph (D). (C) Non-EMA distribution factor For purposes of subparagraph (A)(ii)(II),
“emerging community” applies in that section
the term “emerging community” means a metropolitan area (as defined in section 300ff–17 of this title ) for which there has been reported to and confirmed by the Director of the Centers for Disease Control and Prevention a cumulative total of at least 500, but fewer than 1,000, cases of AIDS during the most recent period of 5 calendar years for which such data are available.
“2006 adjusted amount” applies in that section
the term “2006 adjusted amount” means the amount appropriated for fiscal year 2006 under section 300ff–77(b) of this title (as such section was in effect for such fiscal year), excluding any amount appropriated for such year exclusively for carrying out section 300ff–26 of this title (and, accordingly, distributed under section 300ff–28(a)(2)(I) of this title , as so in effect).
“universal testing of newborns” applies in that section
The term “universal testing of newborns” means HIV/AIDS testing that is administered within 48 hours of delivery to— (A) all infants born in the State; or (B) all infants born in the State whose mother’s HIV/AIDS status is unknown at the time of delivery.
“voluntary opt-out testing” applies in that section
The term “voluntary opt-out testing” means HIV/AIDS testing— (A) that is administered to an individual seeking other health care services; and (B) in which— (i) pre-test counseling is not required but the individual is informed that the individual will receive an HIV/AIDS test and the individual may opt out of such testing; and (ii) for those individuals with a positive test result, post-test counseling (including referrals for care) is provided and confidentiality is protected.;
“medical outcomes” applies in that section
the term “medical outcomes” means those outcomes affecting the HIV-related clinical status of an individual with HIV/AIDS. (e) Specification of early intervention services (1) In general The early intervention services referred to in this section are— (A) counseling individuals with respect to HIV/AIDS in accordance with section 300ff–62 of this title ; (B) testing individuals with respect to HIV/AIDS, including tests to confirm the presence of the disease, tests to diagnose the extent of the deficiency in the immune system, and tests to provide information on appropriate therapeutic measures for preventing and treating the deterioration of the immune system and for preventing and treating …
“support services” applies in that section
the term “support services” means services, subject to the approval of the Secretary, that are needed for individuals with HIV/AIDS to achieve their medical outcomes (such as respite care for persons caring for individuals with HIV/AIDS, outreach services, medical transportation, linguistic services, and referrals for health care and support services). (2) Definition of medical outcomes In this section,
“administrative expenses” applies in that section
The term “administrative expenses” means funds that are to be used by grantees for grant management and monitoring activities, including costs related to any staff or activity unrelated to services or indirect costs. (2) Indirect costs
“indirect costs” applies in that section
The term “indirect costs” means costs included in a Federally negotiated indirect rate. (3) Services
“services” applies in that section
The term “services” means— (A) services that are provided to clients to meet the goals and objectives of the program under this section, including the provision of professional, diagnostic, and therapeutic services by a primary care provider or a referral to and provision of specialty care; and (B) services that sustain program activity and contribute to or help improve services under subparagraph (A).
“emergency area” applies in that section
The term “emergency area” means a geographic area in which there exists— (A) an emergency or disaster declared by the President pursuant to the National Emergencies Act [ 50 U.S.C. 1601 et seq.] or the Robert T. Stafford Disaster Relief and Emergency Assistance Act [ 42 U.S.C. 5121 et seq.]; or (B) a public health emergency declared by the Secretary pursuant to section 247d of this title . (2) Emergency period
“emergency period” applies in that section
The term “emergency period” means the period in which there exists— (A) an emergency or disaster declared by the President pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act; or (B) a public health emergency declared by the Secretary pursuant to section 247d of this title . (c) Unobligated funds If funds under a grant under this section are not expended for an emergency in the fiscal year in which the emergency is declared, such funds shall be returned to the Secretary for reallocation under sections 300ff–13(b) and 300ff–29a of this title.
“personally identifiable information” applies in that section
the term “personally identifiable information” has the meaning given such term under the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996.
“severity of need index” applies in that section
the term “severity of need index” means the index of the relative needs of individuals within a State or area, as identified by a number of different factors, and is a factor or set of factors that is multiplied by the number of living HIV/AIDS cases in a State or area, providing different weights to those cases based on needs. Such factors or set of factors may be different for different components of the provisions under this subchapter.
“AIDS” applies throughout its subchapter
The term “AIDS” means acquired immune deficiency syndrome. (2) Co-occurring conditions
“co-occurring conditions” applies throughout its subchapter
The term “co-occurring conditions” means one or more adverse health conditions in an individual with HIV/AIDS, without regard to whether the individual has AIDS and without regard to whether the conditions arise from HIV. (3) Counseling
“counseling” applies throughout its subchapter
The term “counseling” means such counseling provided by an individual trained to provide such counseling. (4) Family-centered care
“families with HIV/AIDS” applies throughout its subchapter
The term “families with HIV/AIDS” means families in which one or more members have HIV/AIDS. (6) HIV
“family-centered care” applies throughout its subchapter
The term “family-centered care” means the system of services described in this subchapter that is targeted specifically to the special needs of infants, children, women and families. Family-centered care shall be based on a partnership between parents, professionals, and the community designed to ensure an integrated, coordinated, culturally sensitive, and community-based continuum of care for children, women, and families with HIV/AIDS. (5) Families with HIV/AIDS
“HIV” applies throughout its subchapter
The term “HIV” means infection with the human immunodeficiency virus. (7) HIV/AIDS (A) In general
“HIV/AIDS” applies throughout its subchapter
The term “HIV/AIDS” means HIV, and includes AIDS and any condition arising from AIDS. (B) Counting of cases The term “living cases of HIV/AIDS”, with respect to the counting of cases in a geographic area during a period of time, means the sum of— (i) the number of living non-AIDS cases of HIV in the area; and (ii) the number of living cases of AIDS in the area. (C) Non-AIDS cases The term “non-AIDS”, with respect to a case of HIV, means that the individual involved has HIV but does not have AIDS. (8) Human immunodeficiency virus
“human immunodeficiency virus” applies throughout its subchapter
The term “human immunodeficiency virus” means the etiologic agent for AIDS. (9) Official poverty line
“official poverty line” applies throughout its subchapter
The term “official poverty line” means the poverty line established by the Director of the Office of Management and Budget and revised by the Secretary in accordance with section 9902(2) of this title . (10) Person
“person” applies throughout its subchapter
The term “person” includes one or more individuals, governments (including the Federal Government and the governments of the States), governmental agencies, political subdivisions, labor unions, partnerships, associations, corporations, legal representatives, mutual companies, joint-stock companies, trusts, unincorporated organizations, receivers, trustees, and trustees in cases under title 11. (11) State (A) In general
“State” applies throughout its subchapter
The term “State” means each of the 50 States, the District of Columbia, and each of the territories. (B) Territories
“territory” applies throughout its subchapter
The term “territory” means each of American Samoa, Guam, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, the Virgin Islands, the Republic of the Marshall Islands, the Federated States of Micronesia, and Palau. (12) Youth with HIV
“youth with HIV” applies throughout its subchapter
The term “youth with HIV” means individuals who are 13 through 24 years old and who have HIV/AIDS.
“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 or health insurance issuer offering group or individual health insurance coverage furnished to a participant, beneficiary, or enrollee of such plan or coverage 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 …
“emergency department of a hospital” applies throughout its part
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 part
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 [ 42 U.S.C. 1395dd(e)(1)(A) ]. (C) Emergency services (i) In general The term “emergency services”, with respect to an emergency medical condition, means— (I) a medical screening examination (as required under section 1867 of the Social Security Act [ 42 U.S.C.
“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 or coverage, respectively; 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, beneficiary, or enrollee 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 or group or individual health insurance coverage offered by a health insurance issuer 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 or health insurance coverage. (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 or group or individual health insurance coverage offered by a health insurance issuer— (aa) in the case of an item or service for which the plan or coverage 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 the sponsor or issuer 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 …
“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 or group or individual health insurance issuer offering health insurance coverage, 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 or group or individual health insurance coverage offered by a health insurance issuer, 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 or issuer, respectively, for furnishing such item or service under the plan or coverage, respectively. (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 or group or individual health insurance coverage offered by a health insurance issuer, 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 or coverage, respectively. (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, beneficiary, or enrollee of a group health plan or group or individual health insurance coverage offered by a health insurance issuer 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, coverage, or issuer, respectively; such a nonparticipating provider or nonparticipating emergency facility; and such an item or service, the amount determined in accordance with …
“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 or group or individual health insurance coverage offered by a health insurance issuer, an emergency department of a hospital, or an independent freestanding emergency department, that has a contractual relationship directly or indirectly with the plan or issuer, respectively, 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 or health insurance issuer offering group or individual health insurance coverage, a health care facility described in clause (ii) that has a direct or indirect contractual relationship with the plan or issuer, respectively, 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 group or individual health insurance coverage, is each of the following: (I) A hospital (as defined in 1861(e) of the Social Security Act [ 42 U.S.C. 1395x(e) ]).
“participating provider” applies in that section
The term “participating provider” means, with respect to an item or service and a group health plan or group or individual health insurance coverage offered by a health insurance issuer, 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 or issuer, respectively, for furnishing such item or service under the plan or coverage, respectively. (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 and health insurance issuer offering group or individual health insurance coverage— (I) for an item or service furnished during 2022, the median of the contracted rates recognized by the plan or issuer, respectively (determined with respect to all such plans of such sponsor or all such coverage offered by such issuer that are offered within the same insurance market (specified in subclause (I), (II), (III), or (IV) of clause (iv)) as the plan or coverage) as the total maximum payment (including the cost-sharing amount imposed for such item or service and the amount …
“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 or group or individual health insurance coverage offered by a health insurance issuer— (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, coverage, or issuer, respectively; 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 …
“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 or group or individual health insurance coverage offered by a health insurance issuer, a State law that provides for a method for determining the total amount payable under such a plan, coverage, or issuer, respectively (to the extent such State law applies to such plan, coverage, or issuer, subject to section 1144 of title 29 ) in the case of a participant, beneficiary, or enrollee covered under such plan or coverage and receiving such item or service from such a nonparticipating provider or …
“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 300gg–111(a)(3) of this title .
“qualifying payment amount” applies in that section
The term “qualifying payment amount” has the meaning given such term in section 300gg–111(a)(3) of this title . (3) Nonparticipating 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, 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 1395x(dd)(3)(A) of this title ) and is receiving …
“serious and complex condition” applies in that section
The term “serious and complex condition” means, with respect to a participant, beneficiary, or enrollee under a group health plan or group or individual health insurance coverage— (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 is— 1 (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 and a health insurance issuer offering group or individual health insurance coverage, the name, address, specialty, telephone number, and digital contact information of each health care provider or health care facility with which such plan or such issuer has a contractual relationship for furnishing items and services under such plan or such coverage. (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 or health insurance coverage, means the amount spent by a group health plan or health insurance issuer 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 1002(16)(B) of title 29 . (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 (including group health insurance coverage offered in connection with such a 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 (including group health insurance coverage offered in connection with such a plan) established or maintained by a plan sponsor described in clause (ii) or (iii) of section 1002(16)(B) of title 29 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 1395w–3a(c)(6)(B) of this title .
“nonparticipating facility” applies in that section
The term “nonparticipating facility” means— (A) with respect to emergency services (as defined in section 300gg–111(a)(3)(C)(i) of this title ) and a group health plan or group or individual health insurance coverage offered by a health insurance issuer, an emergency department of a hospital, or an independent freestanding emergency department, that does not have a contractual relationship with the plan or issuer, respectively, with respect to the furnishing of such services under the plan or coverage, respectively; and (B) with respect to services described in section 300gg–111(a)(3)(C)(ii) of this title and a group health plan or group or individual health insurance coverage offered by a …
“nonparticipating provider” applies in that section
The terms “nonparticipating provider” and “participating provider” have the meanings given such terms, respectively, in subsection (a)(3) of section 300gg–111 of this title .;
“participating facility” applies in that section
The term “participating facility” means— (A) with respect to emergency services (as defined in clause (i) of section 300gg–111(a)(3)(C) of this title ) that are not described in clause (ii) of such section and a group health plan or group or individual health insurance coverage offered by a health insurance issuer, an emergency department of a hospital, or an independent freestanding emergency department, that has a direct or indirect contractual relationship with the plan or issuer, respectively, with respect to the furnishing of such services under the plan or coverage, respectively; and (B) with respect to services that pursuant to clause (ii) of section 300gg–111(a)(3)(C) of this title …
“participating health care facility” applies in that section
The term “participating health care facility” has the meaning given such term in subsection (b)(2) of section 300gg–111 of this title .;
“participating provider” applies in that section
The terms “nonparticipating provider” and “participating provider” have the meanings given such terms, respectively, in subsection (a)(3) of section 300gg–111 of this title .;
“uninsured individual” applies in that section
the term “uninsured individual” means, with respect to an item or service, an individual who does not have benefits for such item or service under a group health plan, group or individual health insurance coverage offered by a health insurance issuer, Federal health care program (as defined in section 1320a–7b(f) of this title ), or a health benefits plan under chapter 89 of title 5 (or an individual who has benefits for such item or service under a group health plan or individual or group health insurance coverage offered by a health insurance issuer, but who does not seek to have a claim for such item or service submitted to such plan or coverage).
“provider directory information” applies in that section
the term “provider directory information” includes the names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers, and the names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved. (e) Rule of construction Nothing in this section shall be construed to preempt any provision of State law relating to health care provider directories.
“highly compensated individual” applies in that section
The term “highly compensated individual” has the meaning given such term by section 105(h)(5) of title 26 .
“emergency medical condition” applies in that section
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 1395dd(e)(1)(A) of this title . (B) Emergency services
“emergency services” applies in that section
The term “emergency services” means, with respect to an emergency medical condition— (i) a medical screening examination (as required under section 1395dd of this title ) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and (ii) within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under section 1395dd of this title to stabilize the patient.
“noncompliance period” applies in that section
the term “noncompliance period” means, with respect to any failure, the period— (I) beginning on the date such failure first occurs; and (II) ending on the date the failure is corrected. (C) Minimum penalties where failure discovered Notwithstanding clauses (i) and (ii) of subparagraph (D): (i) In general In the case of 1 or more failures with respect to an individual— (I) which are not corrected before the date on which the plan receives a notice from the Secretary of such violation; and (II) which occurred or continued during the period involved; the amount of penalty imposed by subparagraph (A) by reason of such failures with respect to such individual shall not be less than $2,500.
“State” applies in that section
The term “State” includes a State (including the Northern Mariana Islands), any political subdivisions of a State or such Islands, or any agency or instrumentality of either.
“State law” applies in that 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 shall be treated as a State law rather than a law of the United States. (2) State
“aggregate lifetime limit” applies in that section
The term “aggregate lifetime limit” means, with respect to benefits under a group health plan or health insurance coverage, a dollar limitation on the total amount that may be paid with respect to such benefits under the plan or health insurance coverage 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 or health insurance coverage, 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 or health insurance coverage 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 or coverage (as the case may be), 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
“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 (or the health insurance coverage offered in connection with the plan with respect to such benefits) shall be made available by the plan administrator (or the health insurance issuer offering such coverage) 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 or individual health insurance coverage, a leave of absence of such child from a postsecondary educational institution (including an institution of higher education as defined in section 1002 of title 20 ), 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.
“affiliation period” applies throughout its subchapter
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. The organization is not required to provide health care services or benefits during such period and no premium shall be charged to the participant or beneficiary for any coverage during the period. (B) Beginning Such period shall begin on the enrollment date. (C) Runs concurrently with waiting periods An affiliation period under a plan shall run concurrently with any waiting period under the plan.
“creditable coverage” applies throughout its subchapter
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 [ 42 U.S.C. 1395c et seq., 1395j et seq.]. (D) Title XIX of the Social Security Act [ 42 U.S.C. 1396 et seq.], other than coverage consisting solely of benefits under section 1928 [ 42 U.S.C. 1396s ]. (E) Chapter 55 of title 10. (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.
“enrollment date” applies throughout its part
The term “enrollment date” means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for such enrollment. (3) Late enrollee
“late enrollee” applies throughout its part
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 throughout its part
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 Genetic information shall not be treated as a condition described in subsection (a)(1) 1 in the absence of a diagnosis of the condition related to such information. (2) Enrollment date
“TAA-eligible individual” applies throughout its subchapter
The terms “TAA-eligible individual” and “TAA-related loss of coverage” have the meanings given such terms in section 300bb–5(b)(4) of this title . (3) Method of crediting coverage (A) Standard method Except as otherwise provided under subparagraph (B), for purposes of applying subsection (a)(3), 1 a group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period.
“TAA-related loss of coverage” applies throughout its subchapter
The terms “TAA-eligible individual” and “TAA-related loss of coverage” have the meanings given such terms in section 300bb–5(b)(4) of this title . (3) Method of crediting coverage (A) Standard method Except as otherwise provided under subparagraph (B), for purposes of applying subsection (a)(3), 1 a group health plan, and a health insurance issuer offering group or individual health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period.
“waiting period” applies throughout its part
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 subchapter,
“eligible individual” applies throughout its part
the term “eligible individual” means an individual— (1) (A) for whom, as of the date on which the individual seeks coverage under this section, the aggregate of the periods of creditable coverage (as defined in section 2701(c)) 1 is 18 or more months and (B) whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan (or health insurance coverage offered in connection with any such plan); (2) who is not eligible for coverage under (A) a group health plan, (B) part A or part B of title XVIII of the Social Security Act [ 42 U.S.C. 1395c et seq., 1395j et seq.], or (C) a State plan under title XIX of such Act [ 42 U.S.C.
“qualified high risk pool” applies in that section
The term “qualified high risk pool” has the meaning given such term in section 300gg–44(c)(2) of this title , except that a State may elect to meet the requirement of subparagraph (A) of such section (insofar as it requires the provision of coverage to all eligible individuals) through providing for the enrollment of eligible individuals through an acceptable alternative mechanism (as defined for purposes of section 300gg–44 of this title ) that includes a high risk pool as a component. (2) Standard risk rate
“standard risk rate” applies in that section
The term “standard risk rate” means a rate— (A) determined under the State high risk pool by considering the premium rates charged by other health insurers offering health insurance coverage to individuals in the insurance market served; (B) that is established using reasonable actuarial techniques; and (C) that reflects anticipated claims experience and expenses for the coverage involved. (3) State
“State” applies in that section
The term “State” means any of the 50 States and the District of Columbia and includes Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.
“approved clinical trial” applies in that section
the term “approved clinical trial” means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the following subparagraphs: (A) Federally funded trials .— The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following: (i) The National Institutes of Health. (ii) The Centers for Disease Control and Prevention. (iii) The Agency for Health Care Research and Quality. (iv) The Centers for Medicare & Medicaid Services.
“life-threatening condition” applies in that section
the term “life-threatening condition” means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted. (f) Construction Nothing in this section shall be construed to limit a plan’s or issuer’s coverage with respect to clinical trials. (g) Application to FEHBP Notwithstanding any provision of chapter 89 of title 5, this section shall apply to health plans offered under the program under such chapter.
“qualified individual” applies in that section
the term “qualified individual” means an individual who is a participant or beneficiary in a health plan or with coverage described in subsection (a)(1) and who meets the following conditions: (1) The individual is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening disease or condition.
“applicable State authority” applies throughout its subchapter
The term “applicable State authority” means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this subchapter for the State involved with respect to such issuer. (2) Beneficiary
“beneficiary” applies throughout its subchapter
The term “beneficiary” has the meaning given such term under section 3(8) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(8) ]. (3) Bona fide association
“bona fide association” applies throughout its subchapter
The term “bona fide association” means, with respect to health insurance coverage offered in a State, an association which— (A) has been actively in existence for at least 5 years; (B) has been formed and maintained in good faith for purposes other than obtaining insurance; (C) does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee); (D) makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to such members (or individuals eligible for coverage through a member); (E) does not make …
“church plan” applies throughout its subchapter
The term “church plan” has the meaning given such term under section 3(33) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(33) ]. (8) Governmental plan;
“COBRA continuation provision” applies throughout its subchapter
The term “COBRA continuation provision” means any of the following: (A) Section 4980B of title 26 , other than subsection (f)(1) of such section 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 [ 29 U.S.C. 1169 ]. (C) Subchapter XX of this chapter. (5) Employee
“employee” applies throughout its subchapter
The term “employee” has the meaning given such term under section 3(6) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(6) ]. (6) Employer
“employer” applies throughout its subchapter
The term “employer” has the meaning given such term under section 3(5) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(5) ], except that such term shall include only employers of two or more employees. (7) Church plan
“excepted benefits” applies throughout its subchapter
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.
“Exchange” applies throughout its subchapter
The term “Exchange” means an American Health Benefit Exchange established under section 18031 of this title . (e) Definitions relating to markets and small employers For purposes of this subchapter: (1) Individual market (A) In general
“family member” applies throughout its subchapter
The term “family member” means, with respect to any individual— (A) a dependent (as such term is used for purposes of section 2701(f)(2)) 1 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). (16) Genetic information (A) In general
“Federal governmental plan” applies throughout its subchapter
The term “Federal governmental plan” means a governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of such Government. (C) Non-Federal governmental plan .—
“genetic information” applies throughout its subchapter
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 subchapter
The term “genetic services” means— (A) a genetic test; (B) genetic counseling (including obtaining, interpreting, or assessing genetic information); or (C) genetic education. (19) Underwriting purposes
“genetic test” applies throughout its subchapter
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. (18) Genetic services
“governmental plan” applies throughout its subchapter
The term “governmental plan” has the meaning given such term under section 3(32) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(32) ] and any Federal governmental plan. (B) Federal governmental plan .—
“group health insurance coverage” applies in that section
The term “group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan. (5) Individual health insurance coverage
“group health plan” applies in that section
The term “group health plan” means an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974 [ 29 U.S.C. 1002(1) ]) to the extent that the plan provides medical care (as defined in paragraph (2)) and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise. Except for purposes of part C of title XI of the Social Security Act ( 42 U.S.C. 1320d et seq.), such term shall not include any qualified small employer health reimbursement arrangement (as defined in section 9831(d)(2) of title 26 ). (2) Medical care
“health insurance coverage” applies in that section
The term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer. (2) Health insurance issuer