【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 705 条　团体医保计划的特殊规则

(a) 部分小型团体医保计划的一般豁免。在一个计划年度的首日，若某团体医保计划的在职雇员参保人少于 2 人，则本部分各项规定不适用于该团体医保计划（以及配套的团体医保保险保障）。

(b) 部分福利的豁免。如团体医保计划提供第 706 (c)(1) 条所定义的例外福利，则本部分规定不适用于该计划与此类福利相关的业务。

(c) 满足特定条件时，部分福利可豁免适用。

(1) 有限型例外福利。团体医保计划提供第 706 (c)(2) 条规定的有限例外福利，满足以下任一条件的，本部分规定不适用于该类福利：

(A) 该福利通过独立保险保单、保险凭证或者保险合同提供；或者

(B) 该福利不属于本计划的核心组成部分。

(2) 非协调型例外福利。团体医保计划提供第 706 (c)(3) 条规定的例外福利，同时全部满足下列条件的，本部分规定不适用于该类福利：

(A) 该福利通过独立保险保单、保险凭证或者保险合同提供；

(B) 该福利的给付规则，与同一计划发起方运营的其他团体医保计划的福利排除规则之间不存在待遇协调关系；

(C) 针对同一保险事故给付该类福利时，不考量同一计划发起方的其他团体医保计划是否已经就该事故给付保险金。

(3) 补充型例外福利。团体医保计划提供第 706 (c)(4) 条规定的补充类例外福利，且该福利通过独立保险保单、保险凭证或者保险合同提供的，本部分规定不适用于该类福利。

(d) 合伙企业的处理规则。就本部分而言：

(1) 视作团体医保计划：合伙企业设立或运营的某项计划、基金或项目，若若非本款规定，本不属于雇员福利计划；但该计划、基金、项目直接或通过保险、报销等方式，向合伙企业现合伙人、前合伙人及其家属（按本计划定义）提供医疗服务，则除本款第 (2) 项约束外，该计划应当被认定为属于雇员福利计划范畴的团体医保计划。

(2) “雇主” 的定义扩张。针对团体医保计划，“雇主” 一词包含提供该计划的合伙企业，合伙企业针对其合伙人视同雇主。

(3) 团体医保计划 “参保人” 定义扩张：针对团体医保计划，“参保人” 还包括：

(A) 合伙企业设立的团体医保计划项下，该合伙企业的合伙人；

(B) 个体经营者设立的团体医保计划（该计划已有雇员参保）项下，该个体经营者本人；前提是该个体经营者本人有资格、或未来有资格享受本计划福利，或其家属有资格享受相关福利。

‘‘SEC. 705. SPECIAL RULES RELATING TO GROUP HEALTH PLANS.

‘‘(a) GENERAL EXCEPTION FOR CERTAIN SMALL GROUP HEALTH PLANS.—The requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) for any plan year if, on the first day of such plan year, such plan has less than 2 participants who are current employees.

‘‘(b) EXCEPTION FOR CERTAIN BENEFITS.—The requirements of this part shall not apply to any group health plan (and group health insurance coverage) in relation to its provision of excepted benefits described in section 706(c)(1).

‘‘(c) EXCEPTION FOR CERTAIN BENEFITS IF CERTAIN CONDITIONS MET.—

‘‘(1) LIMITED, EXCEPTED BENEFITS.—The requirements of this part shall not apply to any group health plan (and group health insurance coverage offered in connection with a group health plan) in relation to its provision of excepted benefits described in section 706(c)(2) if the benefits—

‘‘(A) are provided under a separate policy, certificate, or contract of insurance; or

‘‘(B) are otherwise not an integral part of the plan.

‘‘(2) NONCOORDINATED, EXCEPTED BENEFITS.—The requirements of this part shall not apply to any group health plan(and group health insurance coverage offered in connection with a group health plan) in relation to its provision of excepted benefits described in section 706(c)(3) if all of the following conditions are met:

‘‘(A) The benefits are provided under a separate policy, certificate, or contract of insurance.

‘‘(B) There is no coordination between the provision of such benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor.

‘‘(C) Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor.

‘‘(3) SUPPLEMENTAL EXCEPTED BENEFITS.—The requirements of this part shall not apply to any group health plan(and group health insurance coverage) in relation to its provision of excepted benefits described in section 706(c)(4) if the benefits are provided under a separate policy, certificate, or contract of insurance.

‘‘(d) TREATMENT OF PARTNERSHIPS.—For purposes of this part—

‘‘(1) TREATMENT AS A GROUP HEALTH PLAN.—Any plan, fund, or program which would not be (but for this subsection) an employee welfare benefit plan and which is established or maintained by a partnership, to the extent that such plan, fund, or program provides medical care (including items and services paid for as medical care) to present or former partners in the partnership or to their dependents (as defined under the terms of the plan, fund, or program), directly or through insurance, reimbursement, or otherwise, shall be treated (subject to paragraph (2)) as an employee welfare benefit plan which is a group health plan.

‘‘(2) EMPLOYER.—In the case of a group health plan, the term ‘employer’ also includes the partnership in relation to any partner.

‘‘(3) PARTICIPANTS OF GROUP HEALTH PLANS.—In the case of a group health plan, the term ‘participant’ also includes—

‘‘(A) in connection with a group health plan maintained by a partnership, an individual who is a partner in relation to the partnership, or

‘‘(B) in connection with a group health plan maintained by a self‑employed individual (under which one or more employees are participants), the self‑employed individual, if such individual is, or may become, eligible to receive a benefit under the plan or such individual’s beneficiaries may be eligible to receive any such benefit.