【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（一）

第 1 编 — 医疗保障准入、可携带性与续保

A 分编 — 团体市场规则

第 1 部分 — 可携带性、准入与续保要求

第 101 条 通过修订《1974 年雇员退休收入保障法》实施

(a) 总则。对《1974 年雇员退休收入保障法》第一编 B 分编作出修订，在末尾新增如下第 7 部分：

第 7 部分 —— 团体医保计划：可携带性、准入以及续保要求

第 701 条 通过限制既往症除外条款提升医保可携带性

（a）既往症除外期限的限制；既往有效保障的累计计算。在遵守本条 (d) 款的前提下，团体医保计划、以及提供团体医保保障的保险机构，针对参保人或受益人，仅在同时满足以下全部条件时，方可设置既往症除外条款：

(1) 该除外条款所针对的身体或精神病症，无论成因，参保人在参保登记日往前倒推 6 个月内，曾获得相关医疗建议、诊断、护理或治疗；

(2) 该除外期限自参保登记日起，最长不得超过 12 个月；迟参保人员最长为 18 个月；

(3) 该既往症除外的时长，应当扣减参保登记日时该参保人 / 受益人已具备的有效保障累计时长（定义见本条 (c)(1) 款）。

(b) 定义。就本部分而言：

(1) 既往症除外条款

(A) 总则：“既往症除外条款”，针对某项保障，指基于某项病症在参保之前就已存在这一事实，对该病症相关福利作出限制或排除；无论参保前是否已经得到该病症的医疗建议、诊断、护理或治疗。

(B) 遗传信息的处理：在没有确诊对应病症的前提下，遗传信息不得被视作本款 (a)(1) 项下的既往病症。

(2) 参保登记日：针对团体医保计划或医保保障下的个人，指该个人办理参保的日期；若更早，则为参保等待期的起始日。

(3) 迟参保人员：团体医保计划下的参保人或受益人，未在以下任一时间段参保的，属于迟参保人员：

(A) 个人首次具备参保资格的窗口期；

(B) 本条 (f) 款规定的特殊参保窗口期。

(4) 等待期：针对团体医保计划与潜在参保人、受益人，指个人需要等待一段时间之后，才有资格享受计划项下保险福利。

(c) 既往有效保障的累计计算规则

(1) 有效保障定义。就本部分而言，“有效保障” 指个人享有下列任一保障：

(A) 团体医保计划；

(B) 医疗保险保障；

(C) 《社会保障法》第十八编 A 部分或 B 部分（联邦老年医保）；

(D) 《社会保障法》第十九编（医疗救助），但仅依据第 1928 条提供的福利除外；

(E) 《美国法典》第 10 编第 55 章（军人及家属医疗保障）；

(F) 印第安人健康服务局或部落机构的医疗项目；

(G) 州设立的高风险医保池；

(H) 《美国法典》第 5 编第 89 章联邦雇员健康保障计划；

(I) 法规定义的公共健康计划；

(J) 《和平队法》第 5 (e) 条项下健康福利计划。

本术语不包括仅提供 “例外福利”（见第 706 (c) 条定义）的保障。

(2) 保障出现重大断档时不计入累计时长

(A) 总则：若某段有效保障结束之后、新参保登记日之前，存在连续 63 天完全没有任何有效保障的时间段，则该段旧的有效保障时长不得计入新计划的累计。

(B) 等待期不视作保障断档。就 (A) 项以及本条 (d)(4) 款，个人处于某医保计划的等待期、或 HMO 联盟期，该段时间不计入 “63 天无保障” 的计算。

(3) 有效保障时长的计算方式

(A) 标准计算方式：除 (B) 项选择替代方案外，团体医保计划、团体医保保险机构计算有效保障时长时，不区分过去实际覆盖的福利种类。

(B) 可选择替代计算方式。团体医保计划或保险机构可以选择按照法规划分的多类福利类目分别计算；该选择对全部参保人、受益人统一适用。采用该方式时，只要在某一类福利下曾经享有过任意等级保障，该段时间就计入该福利类别的有效保障时长。

(C) 计划告知义务。团体医保计划如果选用 (B) 项替代计算方式：

(i) 需要在计划披露文件中显著提示，并在参保人办理参保时告知参保人本计划选用该计算规则；

(ii) 文件说明该规则带来的实际影响。

(4) 有效保障时长的证明。个人有效保障时长，可凭本条 (e) 款所述证明文件，或法规规定的其他方式予以确认。

(d) 例外情形

(1) 新生儿例外。受本款 (4) 项约束：新生儿自出生起 30 天期限结束前已享有有效保障，团体医保计划、保险机构不得对该新生儿设置既往症除外条款。

(2) 被收养儿童例外。受本款 (4) 项约束：18 周岁之前被收养 / 安置待收养的儿童，自收养或安置之日起 30 天期限结束前享有有效保障，则计划和保险机构不得对该儿童设置既往症除外；本规定不适用于收养日期之前的保障。

(3) 怀孕例外。团体医保计划、保险机构不得将怀孕视作既往症并设置除外条款。

(4) 断档失效规则。如果上述 (1)(2) 情形下，个人出现连续 63 天完全没有有效保障，则上述两项例外不再适用。

(e) 保障证明与信息披露

(1) 有效保障证明出具义务

(A) 总则：团体医保计划、团体医保保险机构，应当出具 (B) 项所述书面证明，出具时间节点：

(i) 个人终止本计划保障、或取得 COBRA 延续保障时；

(ii) 个人 COBRA 延续保障终止之时；

(iii) 在保障终止（取前述两个时间中较晚者）之后 24 个月内，收到代表该个人提出的申请。

在可行范围内，第 (i) 项证明可以和 COBRA 通知同步出具。

(B) 证明文件内容：书面证明应当写明：

(i) 该个人在本计划下的有效保障时长、以及 COBRA 延续保障时长（如有）；

(ii) 该个人的等待期、联盟期（如有）。

(C) 保险机构履行义务：团体医保由商业保险保单提供的，由保险机构出具即视为计划完成该义务。

(2) 既往福利信息的披露：若计划 / 保险机构选用本条 (c)(3)(B) 的替代计算方式，且参保人提交了原保障的有效证明文件：

(A) 收到新计划请求时，出具原证明的机构应当及时向新计划披露原计划下各类福利的保障信息；

(B) 出具信息的机构可以向请求方收取合理的信息披露成本。

(3) 法规授权：卫生与公众服务部部长应当制定规则，防止因为机构不提供前述证明、信息，导致个人在后续医保计划中权益受损。

(f) 特殊参保窗口期

(1) 失去其他保障后的参保权利。团体医保计划以及配套保险机构，在全部条件满足的前提下，应当允许原本具备资格但未参保的雇员（或符合条件的家属）办理参保：

(A) 当初向该雇员提供本计划参保机会时，该雇员 / 家属当时已有其他团体医保或医保保障；

(B) 当初拒绝参保时雇员提交书面声明，写明拒绝原因是已有其他医保（前提是计划要求提交该声明，并且已经告知雇员该声明的后果）；

(C) 原保障发生以下情形：

(i) COBRA 延续保障已经用尽；或者

(ii) 非 COBRA 保障因参保资格丧失（离职、分居、离婚、身故、工时缩减）终止，或是雇主停止缴纳保费；

(D) 雇员需要在上述保障终止 / 用尽后的30 天之内提出参保申请。

(2) 家属的特殊参保窗口期

(A) 总则：如果团体医保计划提供家属保障；雇员本人已是参保人（或满足等待期，仅因错过窗口期未参保）；因结婚、生育、收养 / 安置待收养新增家属；则计划应当设置家属特殊参保窗口期，允许新增家属参保；新生儿、被收养儿童情形下，符合条件的配偶也可参保。

(B) 家属特殊参保窗口期：窗口期不少于 30 天，起算时间取两者中较晚：家属保障开放日；结婚 / 生育 / 收养安置发生之日。

(C) 无等待期：在 30 天窗口期内申请家属参保的，保障生效时间：

结婚：收到完整参保申请后次月 1 日或更早；

子女出生：自出生当日生效；

收养或安置待收养：自收养、安置当日生效。

(g) HMO 健康维护组织可采用联盟期替代既往症除外条款

(1) 总则：团体医保计划通过 HMO 提供医保保障时，可以设置联盟期，但必须全部满足：

(A) 对该 HMO 项下保障不设置既往症除外条款；

(B) 联盟期统一适用，不得基于健康状况区别对待；

(C) 联盟期最长 2 个月；迟参保人员最长不超过 3 个月。

(2) 联盟期定义

(A) “联盟期”：HMO 保险保单约定，参保人需要等待一段时间，保障才正式生效；联盟期内，HMO 无需提供医疗服务福利，也不得向参保人收取保费。

(B) 联盟期起算点：参保登记日。

(C) 联盟期与计划的等待期同步并行计算。

(3) 替代方案：HMO 可以采用经州保险监管机构批准的其他方式，用以应对逆向选择风险。

TITLE I—HEALTH CARE ACCESS,

PORTABILITY, AND RENEWABILITY

Subtitle A—Group Market Rules

PART 1—PORTABILITY, ACCESS,

AND RENEWABILITY REQUIREMENTS

SEC. 101. THROUGH THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

(a) IN GENERAL.—Subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new part:

‘‘PART 7—GROUP HEALTH PLAN PORTABILITY, ACCESS,

AND RENEWABILITY REQUIREMENTS

‘‘SEC. 701. INCREASED PORTABILITY THROUGH LIMITATION ON PREEXISTING CONDITION EXCLUSIONS.

‘‘(a) LIMITATION ON PREEXISTING CONDITION EXCLUSION PERIOD;

CREDITING FOR PERIODS OF PREVIOUS COVERAGE.—Subject to subsection (d), a group health plan, and a health insurance issuer offering group health insurance coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if—

‘‘(1) such exclusion relates to a condition (whether physical or mental), regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6‑month period ending on the enrollment date;

‘‘(2) such exclusion extends for a period of not more than 12 months (or 18 months in the case of a late enrollee) after the enrollment date; and

‘‘(3) the period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage (if any, as defined in subsection (c)(1)) applicable to the participant or beneficiary as of the enrollment date.

‘‘(b) DEFINITIONS.—For purposes of this part—

‘‘(1) PREEXISTING CONDITION EXCLUSION.—

‘‘(A) IN GENERAL.—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) in the absence of a diagnosis of the condition related to such information.

‘‘(2) ENROLLMENT DATE.—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.—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.—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, 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).

‘‘(J) A health benefit plan under section 5(e) of the Peace Corps Act (22 U.S.C. 2504(e)).

Such term does not include coverage consisting solely of coverage of excepted benefits (as defined in section 706(c)).

‘‘(2) NOT COUNTING PERIODS BEFORE SIGNIFICANT BREAKS IN COVERAGE.—

‘‘(A) IN GENERAL.—A period of creditable coverage shall not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63‑day period during all of which the individual was not covered under any creditable coverage.

‘‘(B) WAITING PERIOD NOT TREATED AS A BREAK IN COVERAGE.—For purposes of subparagraph (A) and subsection (d)(4), any period that an individual is in a waiting period for any coverage under a group health plan (or for group health insurance coverage) or is in an affiliation period (as defined in subsection (g)(2)) shall not be taken into account in determining the continuous period under subparagraph (A).

‘‘(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, and a health insurance issuer offering group health insurance coverage, shall count a period of creditable coverage without regard to the specific benefits covered during the period.

‘‘(B) ELECTION OF ALTERNATIVE METHOD.—A group health plan, or a health insurance issuer offering group health insurance coverage, may elect to apply subsection (a)(3) based on coverage of benefits within each of several classes or categories of benefits specified in regulations rather than as provided under subparagraph (A). Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election a group health plan or issuer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category.

‘‘(C) PLAN NOTICE.—In the case of an election with respect to a group health plan under subparagraph (B) (whether or not health insurance coverage is provided in connection with such plan), the plan shall—

‘‘(i) prominently state in any disclosure statements concerning the plan, and state to each enrollee at the time of enrollment under the plan, that the plan has made such election, and

‘‘(ii) include in such statements a description of the effect of this election.

‘‘(4) ESTABLISHMENT OF PERIOD.—Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in subsection (e) or in such other manner as may be specified in regulations.

‘‘(d) EXCEPTIONS.—

‘‘(1) EXCLUSION NOT APPLICABLE TO CERTAIN NEWBORNS.—Subject to paragraph (4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion in the case of an individual who, as of the last day of the 30‑day period beginning with the date of birth, is covered under creditable coverage.

‘‘(2) EXCLUSION NOT APPLICABLE TO CERTAIN ADOPTED CHILDREN.—Subject to paragraph (4), a group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion in the case of a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30‑day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. The previous sentence shall not apply to coverage before the date of such adoption or placement for adoption.

‘‘(3) EXCLUSION NOT APPLICABLE TO PREGNANCY.—A group health plan, and health insurance issuer offering group health insurance coverage, may not impose any preexisting condition exclusion relating to pregnancy as a preexisting condition.

‘‘(4) LOSS IF BREAK IN COVERAGE.—Paragraphs (1) and (2) shall no longer apply to an individual after the end of the first 63‑day period during all of which the individual was not covered under any creditable coverage.

‘‘(e) CERTIFICATIONS AND DISCLOSURE OF COVERAGE.—

‘‘(1) REQUIREMENT FOR CERTIFICATION OF PERIOD OF CREDITABLE COVERAGE.—

‘‘(A) IN GENERAL.—A group health plan, and a health insurance issuer offering group health insurance coverage, shall provide the certification described in subparagraph (B)—

‘‘(i) at the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision,

‘‘(ii) in the case of an individual becoming covered under such a provision, at the time the individual ceases to be covered under such provision, and

‘‘(iii) on the request on behalf of an individual made not later than 24 months after the date of cessation of the coverage described in clause (i) or (ii), whichever is later.

The certification under clause (i) may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision.

‘‘(B) CERTIFICATION.—The certification described in this subparagraph is a written certification of—

‘‘(i) the period of creditable coverage of the individual under such plan and the coverage (if any) under such COBRA continuation provision, and

‘‘(ii) the waiting period (if any) (and affiliation period, if applicable) imposed with respect to the individual for any coverage under such plan.

‘‘(C) ISSUER COMPLIANCE.—To the extent that medical care under a group health plan consists of group health insurance coverage, the plan is deemed to have satisfied the certification requirement under this paragraph if the health insurance issuer offering the coverage provides for such certification in accordance with this paragraph.

‘‘(2) DISCLOSURE OF INFORMATION ON PREVIOUS BENEFITS.—In the case of an election described in subsection (c)(3)(B) by a group health plan or health insurance issuer, if the plan or issuer enrolls an individual for coverage under the plan and the individual provides a certification of coverage of the individual under paragraph (1)—

‘‘(A) upon request of such plan or issuer, the entity which issued the certification provided by the individual shall promptly disclose to such requesting plan or issuer information on coverage of classes and categories of health benefits available under such entity’s plan or coverage, and

‘‘(B) such entity may charge the requesting plan or issuer for the reasonable cost of disclosing such information.

‘‘(3) REGULATIONS.—The Secretary shall establish rules to prevent an entity’s failure to provide information under paragraph (1) or (2) with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health insurance coverage.

‘‘(f) SPECIAL ENROLLMENT PERIODS.—

‘‘(1) INDIVIDUALS LOSING OTHER COVERAGE.—A group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the plan (or a dependent of such an employee if the dependent is eligible, but not enrolled, for coverage under such terms) to enroll for coverage under the terms of the plan if each of the following conditions is met:

‘‘(A) The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent.

‘‘(B) The employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or issuer (if applicable) required such a statement at such time and provided the employee with notice of such requirement (and the consequences of such requirement) at such time.

‘‘(C) The employee’s or dependent’s coverage described in subparagraph (A)—

‘‘(i) was under a COBRA continuation provision and the coverage under such provision was exhausted; or

‘‘(ii) was not under such a provision and either the coverage was terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated.

‘‘(D) Under the terms of the plan, the employee requests such enrollment not later than 30 days after the date of exhaustion of coverage described in subparagraph (C)(i) or termination of coverage or employer contribution described in subparagraph (C)(ii).

‘‘(2) FOR DEPENDENT BENEFICIARIES.—

‘‘(A) IN GENERAL.—If—

‘‘(i) a group health plan makes coverage available with respect to a dependent of an individual,

‘‘(ii) the individual is a participant under the plan (or has met any waiting period applicable to becoming a participant under the plan and is eligible to be enrolled under the plan but for a failure to enroll during a previous enrollment period), and

‘‘(iii) a person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption,

the group health plan shall provide for a dependent special enrollment period described in subparagraph (B) during which the person (or, if not otherwise enrolled, the individual) may be enrolled under the plan as a dependent of the individual, and in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage.

‘‘(B) DEPENDENT SPECIAL ENROLLMENT PERIOD.—A dependent special enrollment period under this subparagraph shall be a period of not less than 30 days and shall begin on the later of—

‘‘(i) the date dependent coverage is made available, or

‘‘(ii) the date of the marriage, birth, or adoption or placement for adoption (as the case may be) described in subparagraph (A)(iii).

‘‘(C) NO WAITING PERIOD.—If an individual seeks to enroll a dependent during the first 30 days of such a dependent special enrollment period, the coverage of the dependent shall become effective—

‘‘(i) in the case of marriage, not later than the first day of the first month beginning after the date of the completed request for enrollment is received;

‘‘(ii) in the case of a dependent’s birth, as of the date of such birth; or

‘‘(iii) in the case of a dependent’s adoption or placement for adoption, the date of such adoption or placement for adoption.

‘‘(g) USE OF AFFILIATION PERIOD BY HMOS AS ALTERNATIVE TO PREEXISTING CONDITION EXCLUSION.—

‘‘(1) IN GENERAL.—In the case of a group health plan that offers medical care through health insurance coverage offered by a health maintenance organization, the plan may provide for an affiliation period with respect to coverage through the organization only if—

‘‘(A) no preexisting condition exclusion is imposed with respect to coverage through the organization,

‘‘(B) the period is applied uniformly without regard to any health status‑related factors, and

‘‘(C) such period does not exceed 2 months (or 3 months in the case of a late enrollee).

‘‘(2) AFFILIATION PERIOD.—

‘‘(A) DEFINED.—For purposes of this part, the term ‘affiliation period’ means, 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.

‘‘(3) ALTERNATIVE METHODS.—A health maintenance organization described in paragraph (1) may use alternative methods, from those described in such paragraph, to address adverse selection as approved by the State insurance commissioner or official or officials designated by the State to enforce the requirements of part A of title XXVII of the Public Health Service Act for the State involved with respect to such issuer.