【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（五）

第二十七编：保障健康保险保障的可转移性、可获得性与可续保性

A 部分：团体保险市场改革

第 1 子部分：可转移性、参保权限及续保相关要求

第 2701 条 通过限制既往症除外条款，提升保险保障可转移性

(a) 既往症除外期限限制；既往保障的折算规则

在遵守本条第 (d) 款的前提下，团体健康保险计划以及提供团体健康保险保障的保险机构，针对参保人或受益人仅可在同时满足以下全部三项条件时，设置既往症除外责任：

该除外责任所针对的病症（无论生理或心理病症，不区分致病原因），参保人在参保日往前倒推 6 个月内，曾被建议接受、或实际接受过医疗咨询、诊断、护理或治疗；

该除外责任有效期自参保日起不得超过 12 个月；延迟参保人员最长不超过 18 个月；

应当根据参保人截至参保日已具备的有效保障时长（定义见本条 (c)(1) 款），对上述既往症除外的时长予以扣减折算。

(b) 术语定义

就本部分规定而言：

既往症除外责任

(A) 一般定义：就保险保障而言，指因某一病症在本次参保之前就已存在，从而对该病症相关保险责任进行限制或排除，无论参保前是否实际接受过医疗咨询、诊断、护理或治疗。（《美国法典》第 42 编 §300gg）

(B) 遗传信息处理规则：在尚未确诊对应病症的前提下，遗传信息本身不得被视作本条 (a)(1) 项下的既往病症。

参保日：对于受团体健康保险计划 / 团体健康保险保障的个人，指个人参保日期；若等待期更早，则取等待期首日。

延迟参保人：团体健康保险计划下，参保人 / 受益人，未在以下两个时间段内完成参保的，属于延迟参保人：

(A) 本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。

等待期：针对团体健康保险计划的潜在参保人、受益人，指该个人需要等待一段时间之后，才能够依据计划条款享有保险待遇。

(c) 既往保障时长折算规则

有效保障（Creditable Coverage）定义

就本编规定，“有效保障” 指个人享有下列任意一类保障：

(A) 团体健康保险计划；

(B) 商业健康保险；

(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，不包含仅依据 1928 条提供的保障待遇；

(E) 《美国法典》第 10 编第 55 章（军人医疗保障）；

(F) 印第安人健康服务局或部落机构提供的医疗项目；

(G) 州政府健康保险风险池；

(H) 《美国法典》第 5 编第 89 章联邦雇员健康保险；

(I) 法规定义的公共健康保险计划；

(J) 《和平队法案》第 5 (e) 条项下健康福利计划（《美国法典》第 22 编 §2504 (e)）。

注：仅提供除外类福利的保障，不属于本定义下的有效保障（除外福利定义见第 2791 (c) 条）。

保障中断超过规定时长不再累计既往保障

(A) 一般规则：若个人的一段有效保障结束之后、新计划参保日之前，出现连续 63 天无任何有效保障，该段旧的有效保障时长不再参与新计划的折算。

(B) 等待期不计入保障中断：适用 (A) 项与本条 (d)(4) 款时，个人处于团体保险等待期、或处于隶属期（本条 (g)(2) 定义）的时间，不计入 63 天保障中断的计算。

保障时长折算计算方式

(A) 标准计算方式：除 (B) 项另有选择外，团体健康保险计划、团体保险承保机构，在适用本条 (a)(3) 扣减除外期时，直接累计全部有效保障总时长，不区分过去保障覆盖的具体福利项目。

(B) 可选择替代计算方式：团体保险计划或承保机构，可以选择按照监管法规划分的福利大类，分大类分别核算有效保障时长，替代标准计算方式。该选择必须统一适用于全部参保人与受益人；只要旧保障在某一福利大类下享有任意层级待遇，该段时长即可计入该大类的折算时长。

(C) 保险计划告知义务：团体保险计划如果选择替代计算方式（无论计划是否配套商业保险产品）：

① 需要在计划公开披露文件中显著提示，并且在参保人办理参保时告知参保人本计划采用该替代计算规则；

② 文件中需要说明该计算方式带来的实际影响。

(D) 保险机构告知义务：大小团体市场的保险机构，如果选择替代计算方式：

① 在产品披露文件显著提示，向企业客户销售产品时告知企业本机构采用该计算规则；

② 文件说明该计算方式带来的实际影响。

保障时长的证明方式

个人既往有效保障时长，应当提交本条 (e) 款规定的保障证明文件予以确认，也可采用法规规定的其他方式予以确认。

(d) 例外情形

新生儿例外：受第 (4) 款约束，新生儿自出生起 30 天期限届满前已经享有有效保障的，团体健康保险计划和保险机构，不得对该新生儿设置既往症除外责任。

被收养儿童例外：受第 (4) 款约束，18 周岁之前被收养 / 送养安置的儿童，自收养或安置之日起 30 天期限届满前已享有有效保障的，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完成之前的保障阶段。

怀孕例外：团体健康保险计划、保险机构，不得将妊娠作为既往症设置除外责任。

例外的失效条件：当个人出现连续 63 天无任何有效保障之后，上述第 (1)、(2) 项新生儿、被收养儿童的例外规则，对该个人不再适用。

(e) 保障证明文件以及既往保障信息披露

出具有效保障证明的法定义务

(A) 一般要求：团体保险计划、团体保险承保机构，应当出具 (B) 项规定的书面保障证明：

① 当个人终止本计划保障，或者获得 COBRA 延续保障时；

② 若个人已经取得 COBRA 延续保障，则在该延续保障终止时；

③ 在保障终止（①或②中取较晚时间）之后 24 个月内，接受个人的代为申请请求。

在可行范围内，第①项的证明文件可以和 COBRA 法定通知同步出具。

(B) 证明文件应当载明：

① 该个人在本计划下的有效保障时长、COBRA 延续保障时长（如有）；

② 该个人在本计划项下被施加的等待期（以及隶属期，如适用）。

(C) 保险机构合规认定：当团体计划的医疗服务由商业保险产品提供时，如果保险承保机构按本款出具证明，即视为该团体计划已经履行出具证明的法定义务。

既往福利信息的披露

团体保险计划 / 保险机构采用本条 (c)(3)(B) 替代计算方式时，如果新参保人提交了原保障的有效证明文件：

(A) 新的计划 / 保险机构提出请求的，出具原保障证明文件的机构，应当及时向请求方披露原保险对应的各福利大类覆盖情况；

(B) 原出具机构，可以向请求方收取合理的信息披露成本费用。

部门规章授权：卫生部长应当制定规则，防止因原机构不配合提供历史保障信息，导致个人在新保险计划中权益受损。

(f) 特殊参保窗口期

失去原有保障的人员

团体保险计划，以及配套的保险承保机构，满足全部下列条件时，应当允许原本符合资格但未参保的雇员（或符合资格但未参保的家属）办理参保：

(A) 当初本计划向该雇员 / 家属提供参保机会时，该雇员或家属当时正在其他团体保险保障之下；

(B) 雇员当时书面说明放弃参保的原因是已有其他保险；该书面声明义务，以计划主办方或保险机构要求该声明、并且提前告知雇员声明后果为前提；

(C) 雇员 / 家属原保障发生以下情形之一：

① 属于 COBRA 延续保障，且延续保障已经到期用尽；

② 不属于 COBRA 延续保障：保障因参保资格丧失而终止（包括分居、离婚、身故、离职、工时减少），或雇主停止缴纳该份保险的保费；

(D) 雇员需要在原保障用尽 / 终止之日起30 天内提交参保申请。

家属新增参保（婚姻、生育、收养）

(A) 适用条件，同时满足：

① 团体保险计划可以为参保人的家属提供保障；

② 该个人本身已是本计划参保人（或已经过等待期、具备参保资格，仅错过常规参保窗口期）；

③ 因结婚、子女出生、收养或送养安置，新增家属身份。

团体计划必须设置家属特殊参保窗口期；窗口期内，新增家属（本人未参保的也可由参保人代办）可加入本计划；新生儿、被收养儿童情形下，其配偶如具备参保资格，也可同步参保。

(B) 家属特殊参保窗口期，不少于 30 天，起算时间取以下两者较晚日期：

① 家属保障正式开放的日期；

② 发生结婚、子女出生、收养安置的当日。

(C) 无等待期规则：家属在上述特殊参保窗口期前 30 天内提交参保的，保障生效时间：

① 结婚：不晚于完整参保申请收到后的下一个自然月 1 日；

② 子女出生：自出生当日生效；

③ 收养 / 送养安置：自收养、安置当日生效。

(g) HMO 健康维护组织使用隶属期替代既往症除外条款

一般规则：健康维护组织 HMO，若针对某一款保险产品不使用本条 (a) 款允许的既往症除外条款，则可以设置隶属期，但必须同时满足两项条件：

(A) 隶属期规则统一适用，不得根据个人健康状况区别对待；

(B) 普通参保人隶属期最长 2 个月；延迟参保人最长 3 个月。

隶属期定义

(A) “隶属期”：依据 HMO 保险条款，参保人需要度过该期限之后保险才正式生效；隶属期内，HMO 无需提供医疗服务、不收取保费。

(B) 隶属期起算点：参保日。

(C) 隶属期与等待期并行计算：隶属期和计划本身的等待期时间重叠，同时计算。

其他可选风控手段

第 (1) 款描述的 HMO 机构，在获得所在州保险监管专员（州指定主管官员）批准的前提下，可以采用其他方式应对逆向选择风险，不限于隶属期方案。

‘‘TITLE XXVII—ASSURING PORTABILITY,
AVAILABILITY, AND RENEWABILITY
OF HEALTH INSURANCE COVERAGE

‘‘PART A—GROUP MARKET REFORMS

‘‘Subpart 1—Portability, Access, and Renewability Requirements

‘‘SEC. 2701. 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.
42 USC 300gg.110 STAT. 1956 PUBLIC LAW 104–191—AUG. 21, 1996
‘‘(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 title, 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 2791(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, 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.
‘‘(D) ISSUER NOTICE.—In the case of an election under subparagraph (B) with respect to health insurance coverage offered by an issuer in the small or large group market, the issuer—
‘‘(i) shall prominently state in any disclosure statements concerning the coverage, and to each employer at the time of the offer or sale of the coverage, that the issuer has made such election, and
‘‘(ii) shall include in such statements a description of the effect of such 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 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.—A health maintenance organization which offers health insurance coverage in connection with a group health plan and which does not impose any preexisting condition exclusion allowed under subsection (a) with respect to any particular coverage option may impose an affiliation period for such coverage option, but only if—
‘‘(A) such period is applied uniformly without regard to any health status‑related factors; and
‘‘(B) 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 title, 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.

‘‘(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 this part for the State involved with respect to such issuer.