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1 [1] (November 13, 2019)

handle is hein.crs/govbbry0001 and id is 1 raw text is: _ M t .......... November 13, 2019 Applicability of Federal Requirements to Selected Health Coverage Arrangements: An Overview A majority of individuals in the United States have private health insurance coverage. In general, health plans sold in the private health insurance market (i.e., individual coverage, small- and large-group coverage, and self-insured plans) must comply with applicable federal and state health insurance requirements. The federal requirements are codified in Title XXVII of the Public Health Service Act (PHSA), Part 7 of the Employee Retirement Income Security Act of 1974 (ERISA), and Chapter 100 of the Internal Revenue Code (IRC). They relate to how coverage is offered and issued, the benefits it must cover, and how it is priced, among other issues. Such requirements include the prohibition of preexisting condition exclusions and requirements to cover certain benefits, such as maternity care. However, not all private health coverage arrangements comply with federal health insurance requirements. This includes exempted health coverage arrangements and noncompliant health coverage arrangements, as discussed below. This document provides an overview of such arrangements. This document is adapted from the CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements. See the report for further description of each arrangement, explanation of each arrangement's current status and history with respect to complying with federal health insurance requirements, and relevant statutory and regulatory citations. The report also includes information about whether and how the arrangements are subject to state regulatory authority and provides enrollment estimates (where available). Appica iit Feder,-'al NHealt insu rance RequiremenAs to Selected Arrangemen ts Some health coverage arrangements that consumers may purchase from private health insurers or other private organizations do not comply with some or all federal health insurance requirements. The arrangements listed in Table 1 can be divided into two broad categories, as termed for purposes of this document: * Exempted Health Coverage Arrangements: Those that meet a federal definition of health insurance but are exempt from compliance with some or all applicable federal health insurance requirements. * Noncompliant Health Coverage Arrangements: Those that the federal government has not explicitly exempted from compliance with federal health insurance requirements and that do not necessarily comply with those requirements. Table I. Applicability of Federal Health Insurance Requirements to Selected Arrangements Health Coverage Applicability of Federal Health Arrangement IsrneRequirements Exempted Health Coverage Arrangements Group Health Plans Covering Fewer Than Two Current Employees Exempt from complying with all Excepted Benefits requirements Short-Term, Limited- Duration Insurance Student Health Insurance Exempt from complying with some Coverage or all requirements Self-Insured, Nonfederal Governmental Plans Exempt from complying with some Grandfathered Plans requirements Transitional Plans Noncompliant Health Coverage Arrangements Health Care Sharing Does not necessarily comply with Ministries federal health insurance Farm Bureau Coverage requirements Source: CRS analysis of federal statute and regulations. Notes: This table is adapted from Table I in CRS Report R46003, Applicability of Federal Requirements to Selected Health Coverage Arrangements. See that table for more detail and citations. Exempted Healt Coverage Arrangeme rints Most of the arrangements identified in Table 1 are exempt from compliance with some or all federal health insurance requirements. The exemptions are described in federal statute, regulations, or guidance. G.roup Heakt Plans Covering Fewer Than Two Current Employees Both fully insured and self-insured group health plans covering fewer than two current employees are exempt from all federal health insurance requirements. This includes retiree-only plans, provided they cover fewer than two current employees. The exemption was established in the Health Insurance Portability and Accountability Act (HIPAA; P.L. 104-191), which was enacted in 1996. Ecepted Beeft In general, health plans in their provision of excepted benefits are exempt from all federal health insurance requirements (when specified conditions are met). A diverse collection of insurance benefits can be considered excepted benefits, including auto liability insurance, limited-scope dental and vision benefits, specific disease coverage, and supplemental Medicare plans (i.e., Medigap tps//r'eprs fonres. o N 1 10 LU

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