【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（二）

第 702 条 禁止基于健康状况对参保人和受益人实施歧视

(a) 参保资格

(1) 总则。在遵守第 (2) 款的前提下，团体医保计划，以及为团体医保计划提供团体医保保障的保险机构，不得基于个人或其家属的下列任何与健康状况相关的因素，制定个人参保（含续保）资格规则：

(A) 健康状况；

(B) 医疗状况（包含身体疾病与精神疾病）；

(C) 理赔记录；

(D) 医疗服务接受记录；

(E) 既往医疗史；

(F) 遗传信息；

(G) 可保性证明（包含家庭暴力行为所引发的病症）；

(H) 残疾。

(2) 不适用于福利与除外责任。在不违背第 701 条的前提下，第 (1) 款不得被解释为：

(A) 要求团体医保计划或团体医保保障提供计划条款并未约定的特定保险福利；

(B) 阻止该计划或保险保障，对计划内同等处境参保人员，设置保险福利的额度、等级、覆盖范围与性质方面的限制。

(3) 释义。就第 (1) 款而言，参保资格相关规则，包含针对参保设置的各类等待期规则。

(b) 保费缴纳

(1) 总则。团体医保计划，以及为团体医保计划提供医保保障的保险机构，不得基于个人或其家属的任何健康相关因素，要求该个人缴纳高于本计划同等处境参保人员的保费或分摊费用，并以此作为参保或续保的条件。

(2) 释义。本条第 (1) 款不得被解释为：

(A) 限制向雇主收取团体医保计划保障费用的金额；

(B) 禁止团体医保计划以及保险机构，为鼓励参与健康促进、疾病预防项目，设置保费折扣、返现，或是调整共付额、免赔额。

第 703 条 多雇主计划与多雇主福利安排下的保证续保权利

属于多雇主计划或者多雇主福利安排的团体医保计划，不得拒绝为员工参保的雇主继续提供相同或不同保障，仅可基于以下理由拒绝：

(1) 雇主未缴纳分摊款项；

(2) 雇主存在欺诈，或对重要事实作出故意虚假陈述；

(3) 雇主未遵守计划重要条款；

(4) 计划停止在某一地理区域提供任何保障；

(5) 如果该计划通过网络型保险方案提供福利，不再存在由该雇主参保、在网络服务区域居住 / 工作的参保人员；且本项规则统一适用，不考虑雇主理赔记录、参保人员及其家属的健康相关因素；

(6) 雇主未能履行适用集体谈判协议条款、未续签需要向计划缴纳费用的集体谈判协议，或是不再雇佣本计划覆盖的员工。

第 704 条 法律优先适用；州的灵活性；条文释义

(a) 州法律对保险机构继续适用

(1) 总则。受制于第 (2) 款，且除本条 (b) 款另有规定之外，本部分条文，不得被解释为取代仅针对团体医保保险机构的州法律所确立、实施或延续的标准与要求；除非该州标准会阻碍本部分法定要求落地实施。

(2) 团体医保计划继续适用 ERISA 优先规则。本部分内容，不改动、不影响《雇员退休收入保障法》第 514 条针对团体医保计划的法律优先适用规则。

(b) 可携带性要求的特殊规则

(1) 总则。受制于第 (2) 款，本部分中适用于保险机构团体医保保障的条文，优先于州法律中针对第 701 条既往症除外规则、且标准与联邦条文不一致的任何规定。

(2) 例外情形。仅针对保险机构提供的团体医保保障，州法律出现以下情形时，联邦条文不取代州法律：

(A) 将第 701 (a)(1) 的 “6 个月期限” 替换为更短时长；

(B) 将第 701 (a)(2) 的 “12 个月”“18 个月” 替换为更短时长；

(C) 将第 701 (c)(2)(A)、701 (d)(4) 的 “63 天” 替换为更长天数；

(D) 将第 701 (b)(2)、701 (d)(1) 的 “30 天期限” 替换为更长期限；

(E) 在第 701 (d) 列举情形之外，禁止设置既往症除外，或是扩大该条例外保护范围；

(F) 设置第 701 (f) 未规定的特殊参保窗口期；

(G) 缩短第 701 (g)(1)(B) 允许的最长联盟期。

(c) 释义规则。本部分不得解释为强制团体医保计划、团体医保保障提供计划条款之外的特定保险福利。

(d) 定义

(1) 州法律：“州法律” 包括各州具有法律效力的法律、判决、规则、条例以及其他州层面规范性文件。仅适用于哥伦比亚特区的美国联邦法律，视作州法律，而非联邦法律。

(2) 州：“州” 包含各州、北马里亚纳群岛，各州以及北马里亚纳群岛的下级行政单位，以及它们的机构与职能部门。

‘‘SEC. 702. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH STATUS.

‘‘(a) IN ELIGIBILITY TO ENROLL.—

‘‘(1) IN GENERAL.—Subject to paragraph (2), a group health plan, and a health insurance issuer offering group health insurance coverage in connection with a group health plan, may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan based on any of the following health status‑related factors in relation to the individual or a dependent of the individual:

‘‘(A) Health status.

‘‘(B) Medical condition (including both physical and mental illnesses).

‘‘(C) Claims experience.

‘‘(D) Receipt of health care.

‘‘(E) Medical history.

‘‘(F) Genetic information.

‘‘(G) Evidence of insurability (including conditions arising out of acts of domestic violence).

‘‘(H) Disability.

‘‘(2) NO APPLICATION TO BENEFITS OR EXCLUSIONS.—To the extent consistent with section 701, paragraph (1) shall not be construed—

‘‘(A) to require a group health plan, or group health insurance coverage, to provide particular benefits other than those provided under the terms of such plan or coverage, or

‘‘(B) to prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent,

or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.

‘‘(3) CONSTRUCTION.—For purposes of paragraph (1), rules for eligibility to enroll under a plan include rules defining any applicable waiting periods for such enrollment.

‘‘(b) IN PREMIUM CONTRIBUTIONS.—

‘‘(1) IN GENERAL.—A group health plan, and a health insurance issuer offering health insurance coverage in connection with a group health plan, may not require any individual(as a condition of enrollment or continued enrollment under the plan) to pay a premium or contribution which is greater than such premium or contribution for a similarly situated individual enrolled in the plan on the basis of any health status‑related factor in relation to the individual or to an individual enrolled under the plan as a dependent of the individual.

‘‘(2) CONSTRUCTION.—Nothing in paragraph (1) shall be construed—

‘‘(A) to restrict the amount that an employer may be charged for coverage under a group health plan; or

‘‘(B) to prevent a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

‘‘SEC. 703. GUARANTEED RENEWABILITY IN MULTIEMPLOYER PLANS AND MULTIPLE EMPLOYER WELFARE ARRANGEMENTS.

‘‘A group health plan which is a multiemployer plan or which is a multiple employer welfare arrangement may not deny an employer whose employees are covered under such a plan continued access to the same or different coverage under the terms of such a plan, other than—

‘‘(1) for nonpayment of contributions;

‘‘(2) for fraud or other intentional misrepresentation of material fact by the employer;

‘‘(3) for noncompliance with material plan provisions;

‘‘(4) because the plan is ceasing to offer any coverage in a geographic area;

‘‘(5) in the case of a plan that offers benefits through a network plan, there is no longer any individual enrolled through the employer who lives, resides, or works in the service area of the network plan and the plan applies this paragraph uniformly without regard to the claims experience of employers or any health status‑related factor in relation to such individuals or their dependents; and

‘‘(6) for failure to meet the terms of an applicable collective bargaining agreement, to renew a collective bargaining or other agreement requiring or authorizing contributions to the plan, or to employ employees covered by such an agreement.

‘‘SEC. 704. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

‘‘(a) CONTINUED APPLICABILITY OF STATE LAW WITH RESPECT TO HEALTH INSURANCE ISSUERS.—

‘‘(1) IN GENERAL.—Subject to paragraph (2) and except as provided in subsection (b), this part shall not be construed to supersede any provision of State law which establishes,

implements, or continues in effect any standard or requirement

solely relating to health insurance issuers in connection with

group health insurance coverage except to the extent that such

standard or requirement prevents the application of a requirement of this part.

‘‘(2) CONTINUED PREEMPTION WITH RESPECT TO GROUP HEALTH PLANS.—Nothing in this part shall be construed to affect or modify the provisions of section 514 with respect to group health plans.

‘‘(b) SPECIAL RULES IN CASE OF PORTABILITY REQUIREMENTS.—

‘‘(1) IN GENERAL.—Subject to paragraph (2), the provisions of this part relating to health insurance coverage offered by a health insurance issuer supersede any provision of State law which establishes, implements, or continues in effect a standard or requirement applicable to imposition of a preexisting condition exclusion specifically governed by section 701 which differs from the standards or requirements specified in such section.

‘‘(2) EXCEPTIONS.—Only in relation to health insurance coverage offered by a health insurance issuer, the provisions of this part do not supersede any provision of State law to the extent that such provision—

‘‘(A) substitutes for the reference to‘6‑month period’in section 701(a)(1) a reference to any shorter period of time;

‘‘(B) substitutes for the reference to‘12 months’and‘18 months’in section 701(a)(2) a reference to any shorter period of time;

‘‘(C) substitutes for the references to‘63 days’in sections 701 (c)(2)(A) and (d)(4)(A) a reference to any greater number of days;

‘‘(D) substitutes for the reference to‘30‑day period’in sections 701 (b)(2) and (d)(1) a reference to any greater period;

‘‘(E) prohibits the imposition of any preexisting condition exclusion in cases not described in section 701(d) or expands the exceptions described in such section;

‘‘(F) requires special enrollment periods in addition to those required under section 701(f); or

‘‘(G) reduces the maximum period permitted in an affiliation period under section 701(g)(1)(B).

‘‘(c) RULES OF CONSTRUCTION.—Nothing in this part shall be construed as requiring a group health plan or health insurance coverage to provide specific benefits under the terms of such plan or coverage.

‘‘(d) DEFINITIONS.—For purposes of this section—

‘‘(1) STATE LAW.—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.—The term‘State’includes a State, the Northern Mariana Islands, any political subdivisions of a State or such Islands, or any agency or instrumentality of either.