【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（十）

第 2723 条 联邦法优先适用；州的灵活性；解释规则

(a) 州法律对保险机构继续适用

（1）一般规定：受本条第（2）款约束，且本条 (b) 款另有规定除外，本部分以及 C 部分中与本部分相关的条文，不视为取代各州仅针对团体健康保险业务项下保险机构制定、实施或持续生效的标准或要求；但如果该州标准或要求阻碍本部分规定落地实施的，则不在此限。

（2）团体健康保险计划层面继续适用联邦优先规则：本部分任何条文，均不视为改变或修订《1974 年雇员退休收入保障法》第 514 条中关于团体健康保险计划的规定。

(b) 可携性要求项下特殊规则

（1）一般规定：受本条第（2）款约束，本部分中针对保险机构提供的健康保险产品的规定，优先于州法律中针对既往症除外责任（该事项专门由第 701 条调整）所制定、实施或持续生效，且与第 701 条确立标准不一致的任何规范。

（2）例外情形：仅针对保险机构销售的健康保险产品，若州法律存在如下规定，则本部分条文不取代该州法律：

  (i) 将第 2701 (a)(1) 条的 “6 个月期限” 替换为更短的期限；

  (ii) 将第 2701 (a)(2) 条的 “12 个月”“18 个月” 替换为更短的期限；

  (iii) 将第 2701 (c)(2)(A)、第 2701 (d)(4)(A) 条的 “63 天” 替换为更长天数；

  (iv) 将第 2701 (b)(2)、第 2701 (d)(1) 条的 “30 日期限” 替换为更长期限；

  (v) 在第 2701 (d) 条未规定的情形下禁止适用既往症除外责任，或者扩大该条的例外范围；

  (vi) 在第 2701 (f) 条要求的特殊参保期之外增设其他特殊参保期；

  (vii) 缩短第 2701 (g)(1)(B) 条规定的隶属期最长时限。

(c) 解释规则

本部分任何条文，不得被解释为强制团体健康保险计划或健康保险产品必须提供某类特定保险待遇。

(d) 定义

（1）州法律：“州法律” 包括各州具有法律效力的全部法律、裁判、规则、规章以及其他州层面的规范性文件。仅适用于哥伦比亚特区的联邦法律，视作州法律，而不视为联邦法律。

（2）州：“州” 包括各州（含北马里亚纳群岛）、州 / 北马里亚纳群岛的行政区划，以及二者的机构与职能部门。

C 部分 —— 定义；杂项规定

第 2791 条 定义

(a) 团体健康保险计划

（1）定义：“团体健康保险计划” 指《1974 年雇员退休收入保障法》第 3 (1) 条定义的雇员福利保障计划，该计划直接通过保险、报销或者其他方式，向雇员及其被扶养人（计划文本定义）提供医疗服务（见本款第 (2) 项，包含按医疗服务对待的商品与服务）。

（2）医疗服务：“医疗服务” 指为以下事项支付的费用：

  (A) 疾病的诊断、治愈、缓解、治疗或者预防，或是旨在改变人体身体构造或身体机能的相关支出；

  (B) 主要为实现、且为实现上述 (A) 项医疗服务所必需的交通费用；

  (C) 为覆盖上述 (A)(B) 项医疗服务所投保的保险费用。

（3）通知条款下特定计划视作团体健康保险计划：提供第 2701 (c)(1) 条 (C)(D)(E)(F) 项所述有效保障的项目，在适用第 2701 (e) 条时，视为团体健康保险计划。

(b) 健康保险相关定义

（1）健康保险保障：“健康保险保障” 指保险机构出具的住院或医疗保单、凭证、团体医疗服务合同、健康维护组织合同项下的医疗待遇；可以直接提供，也可以通过保险、报销等方式提供，包含按医疗服务对待的各类商品与服务。

（2）健康保险承保机构：“健康保险承保机构” 指在某州取得保险经营许可、受该州保险监管法律约束（《1974 年雇员退休收入保障法》第 514 (b)(2) 条含义）的保险公司、保险服务机构或保险组织，包含第 (3) 项定义的健康维护组织。该术语不包含团体健康保险计划本身。

（3）健康维护组织：“健康维护组织” 指：

  (A) 联邦认证的健康维护组织（第 1301 (a) 条定义）；

  (B) 州法律认可的健康维护组织；或者

  (C) 州法律以同等偿付能力标准监管的同类机构。

（4）团体健康保险保障：“团体健康保险保障” 指依附团体健康保险计划所提供的健康保险产品。

（5）个人健康保险保障：“个人健康保险保障” 指在个人保险市场向自然人销售的保险产品，不含短期有限期限保险。

(c) 除外类保险待遇

本篇中，“除外类保险待遇” 指满足以下一项或多项（可组合）的保险待遇：

（1）不受本规则约束的待遇

  (A) 仅意外伤害保障，或残疾收入保险，或二者组合；

  (B) 责任保险的附加保障；

  (C) 责任保险，含一般责任险、机动车责任险；

  (D) 工伤赔偿保险或同类保险；

  (E) 机动车医疗赔付保险；

  (F) 信贷类专项保险；

  (G) 企业现场医务室保障；

  (H) 规章另行规定的其他同类保险，医疗保障仅为次要、附带保障。

（2）单独提供才不受约束的待遇

  (A) 限定范围的牙科或眼科保障；

  (B) 长期照护、养老院照护、居家照护、社区照护，或其组合；

  (C) 规章规定的其他同类有限保障。

（3）作为独立、非协同待遇才不受约束的待遇

  (A) 仅针对特定疾病的保险保障；

  (B) 住院津贴保险或其他固定给付型津贴保险。

（4）作为独立保单才不受约束的待遇：联邦医疗保险补充保险（《社会保障法》第 1882 (g)(1) 条定义）、《美国法典》第 10 编第 55 章项下保险的补充保障，以及团体健康保险计划配套的同类补充保险。

(d) 其他定义

（1）适格州主管机关：就某一州内保险机构而言，“适格州主管机关” 指该州保险监理专员，或者州指定的、负责在本州对该保险机构执行本篇要求的官员。

（2）受益人：“受益人” 含义同《1974 年雇员退休收入保障法》第 3 (8) 条。

（3）合法行业协会：针对某州销售的健康保险产品，“合法行业协会” 指满足全部如下条件的协会：

  (A) 已经实际存续至少 5 年；

  (B) 设立并善意运营，设立目的并非单纯获取保险；

  (C) 不以个人健康状况相关因素（雇员或雇员家属）作为入会条件；

  (D) 通过协会提供保险时，不得基于会员（或可通过会员参保人员）的健康状况，拒绝向任何会员提供保险；

  (E) 仅向本协会会员提供该保险产品；

  (F) 满足州法律规定的其他额外要求。

（4）COBRA 延续参保条款：“COBRA 延续参保条款” 指下列任一文件：

  (A) 《1986 年国内税收法典》第 4980B 条，但该条 (f)(1) 款中与儿童疫苗相关部分除外；

  (B) 《1974 年雇员退休收入保障法》第一编 B 分编第 6 部分，第 609 条除外；

  (C) 本法第二十二编。

（5）雇员：“雇员” 含义同《1974 年雇员退休收入保障法》第 3 (6) 条。

（6）雇主：“雇主” 含义同《1974 年雇员退休收入保障法》第 3 (5) 条，但仅包含雇员人数 2 人及以上的雇主。

（7）教会计划：“教会计划” 含义同《1974 年雇员退休收入保障法》第 3 (33) 条。

（8）政府计划

  (A) “政府计划” 含义同《1974 年雇员退休收入保障法》第 3 (32) 条，同时包含各类联邦政府计划。

  (B) 联邦政府计划：联邦政府或其机构、职能部门为本单位雇员设立、维持的政府保险计划。

  (C) 非联邦政府计划：不属于联邦政府计划的其他政府计划。

（9）与健康状况相关的因素：含义见第 2702 (a)(1) 条所列各项因素。

（10）网络定点计划：“网络定点计划” 指保险机构的保险产品，医疗服务的费用结算与服务提供（含计入医疗服务的商品、服务）全部或部分，由与保险机构签约的固定医疗服务商网络完成。

（11）参保人：“参保人” 含义同《1974 年雇员退休收入保障法》第 3 (7) 条。

（12）收养安置定义：涉及将儿童交由他人收养安置时，“安置” 指该人为预备收养，承担对该儿童全部或部分抚养的法定义务；该抚养法定义务终止，则收养安置同时终止。

（13）计划发起方：“计划发起方” 含义同《1974 年雇员退休收入保障法》第 3 (16)(B) 条。

（14）州：“州” 指美国各州、哥伦比亚特区、波多黎各、美属维尔京群岛、关岛、美属萨摩亚、北马里亚纳群岛。

(e) 保险市场与小企业雇主相关定义

本篇适用时：

（1）个人保险市场

  (A) 一般规定：“个人保险市场” 指向自然人销售、不依附团体健康保险计划的健康保险市场。

  (B) 极小团体的处理规则

    (i) 一般：受第 (ii) 项约束，团体计划年度首日在职参保雇员不足 2 人的团体保险产品，视作个人保险市场产品。

    (ii) 州例外：如果某州选择将上述 (i) 项产品纳入小型团体市场监管，则不适用前述规则。

（2）大型雇主：就自然年、计划年度下的团体健康保险计划而言，“大型雇主” 指上一自然年工作日平均雇员不少于 51 人，且计划年度首日雇员不少于 2 人的雇主。

（3）大型团体保险市场：“大型团体保险市场” 指个人通过大型雇主设立的团体健康保险计划，为本人及家属获取保险保障的保险市场。

（4）小型雇主：就自然年、计划年度下的团体健康保险计划而言，“小型雇主” 指上一自然年工作日平均雇员人数不少于 2 人、不超过 50 人，且计划年度首日雇员不少于 2 人的雇主。

（5）小型团体保险市场：“小型团体保险市场” 指个人通过小型雇主设立的团体健康保险计划，为本人及家属获取保险保障的保险市场。

（6）判断雇主规模的适用规则

  (A) 雇主合并计算规则：依据《1986 年国内税收法典》第 414 条 (b)(c)(m)(o) 款视作单一雇主的全部主体，统一按一个雇主计算。

  (B) 上一年度尚未成立的雇主：若雇主上一整个自然年尚未设立，则以本自然年工作日合理预估平均雇员数量，区分属于小型雇主还是大型雇主。

  (C) 承继主体：本款所称雇主，包含该雇主的业务承继主体。

SEC. 2723. 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 and part C insofar as it relates to 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 of the Employee Retirement Income Security Act of 1974 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:   (i) substitutes for the reference to “6‑month period” in section 2701(a)(1) a reference to any shorter period of time;   (ii) substitutes for the reference to “12 months” and “18 months” in section 2701(a)(2) a reference to any shorter period of time;   (iii) substitutes for the references to “63” days in sections 2701(c)(2)(A) and 2701(d)(4)(A) a reference to any greater number of days;   (iv) substitutes for the reference to “30‑day period” in sections 2701(b)(2) and 2701(d)(1) a reference to any greater period;   (v) prohibits the imposition of any preexisting condition exclusion in cases not described in section 2701(d) or expands the exceptions described in such section;   (vi) requires special enrollment periods in addition to those required under section 2701(f); or   (vii) reduces the maximum period permitted in an affiliation period under section 2701(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 (including the Northern Mariana Islands), any political subdivisions of a State or such Islands, or any agency or instrumentality of either.

PART C—DEFINITIONS; MISCELLANEOUS PROVISIONS

SEC. 2791. DEFINITIONS.

(a) GROUP HEALTH PLAN.(1) DEFINITION. — The term “group health plan” means an employee welfare benefit plan (as defined in section 3(1) of the Employee Retirement Income Security Act of 1974) to the extent that the plan provides medical care (as defined in paragraph (2)) and including items and services paid for as medical care) to employees or their dependents (as defined under the terms of the plan) directly or through insurance, reimbursement, or otherwise.

(2) MEDICAL CARE. — The term “medical care” means amounts paid for:   (A) the diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body;   (B) amounts paid for transportation primarily for and essential to medical care referred to in subparagraph (A); and   (C) amounts paid for insurance covering medical care referred to in subparagraphs (A) and (B).

(3) TREATMENT OF CERTAIN PLANS AS GROUP HEALTH PLAN FOR NOTICE PROVISION. — A program under which creditable coverage described in subparagraph (C), (D), (E), or (F) of section 2701(c)(1) is provided shall be treated as a group health plan for purposes of applying section 2701(e).

(b) DEFINITIONS RELATING TO HEALTH INSURANCE.(1) HEALTH INSURANCE COVERAGE. — The term “health insurance coverage” means benefits consisting of medical care (provided directly, through insurance or reimbursement, or otherwise and including items and services paid for as medical care) under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by a health insurance issuer.

(2) HEALTH INSURANCE ISSUER. — The term “health insurance issuer” means an insurance company, insurance service, or insurance organization (including a health maintenance organization, as defined in paragraph (3)) which is licensed to engage in the business of insurance in a State and which is subject to State law which regulates insurance (within the meaning of section 514(b)(2) of the Employee Retirement Income Security Act of 1974). Such term does not include a group health plan.

(3) HEALTH MAINTENANCE ORGANIZATION. — The term “health maintenance organization” means:   (A) a Federally qualified health maintenance organization (as defined in section 1301(a));   (B) an organization recognized under State law as a health maintenance organization; or   (C) a similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization.

(4) GROUP HEALTH INSURANCE COVERAGE. — The term “group health insurance coverage” means, in connection with a group health plan, health insurance coverage offered in connection with such plan.

(5) INDIVIDUAL HEALTH INSURANCE COVERAGE. — The term “individual health insurance coverage” means health insurance coverage offered to individuals in the individual market, but does not include short‑term limited duration insurance.

(c) EXCEPTED BENEFITS. — For purposes of this title, the term “excepted benefits” means benefits under one or more (or any combination thereof) of the following: (1) BENEFITS NOT SUBJECT TO REQUIREMENTS.  (A) Coverage only for accident, or disability income insurance, or any combination thereof.   (B) Coverage issued as a supplement to liability insurance.   (C) Liability insurance, including general liability insurance and automobile liability insurance.   (D) Workers’ compensation or similar insurance.   (E) Automobile medical payment insurance.   (F) Credit‑only insurance.   (G) Coverage for on‑site medical clinics.   (H) Other similar insurance coverage, specified in regulations, under which benefits for medical care are secondary or incidental to other insurance benefits.

(2) BENEFITS NOT SUBJECT TO REQUIREMENTS IF OFFERED SEPARATELY.  (A) Limited scope dental or vision benefits.   (B) Benefits for long‑term care, nursing home care, home health care, community‑based care, or any combination thereof.   (C) Such other similar, limited benefits as are specified in regulations.

(3) BENEFITS NOT SUBJECT TO REQUIREMENTS IF OFFERED AS INDEPENDENT, NONCOORDINATED BENEFITS.  (A) Coverage only for a specified disease or illness.   (B) Hospital indemnity or other fixed indemnity insurance.

(4) BENEFITS NOT SUBJECT TO REQUIREMENTS IF OFFERED AS SEPARATE INSURANCE POLICY. — Medicare supplemental health insurance (as defined under section 1882(g)(1) of the Social Security Act), coverage supplemental to the coverage provided under chapter 55 of title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan.

(d) OTHER DEFINITIONS.(1) APPLICABLE STATE AUTHORITY. — The term “applicable State authority” means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this title for the State involved with respect to such issuer.

(2) BENEFICIARY. — The term “beneficiary” has the meaning given such term under section 3(8) of the Employee Retirement Income Security Act of 1974.

(3) BONA FIDE ASSOCIATION. — The term “bona fide association” means, with respect to health insurance coverage offered in a State, an association which:   (A) has been actively in existence for at least 5 years;   (B) has been formed and maintained in good faith for purposes other than obtaining insurance;   (C) does not condition membership in the association on any health status‑related factor relating to an individual (including an employee of an employer or a dependent of an employee);   (D) makes health insurance coverage offered through the association available to all members regardless of any health status‑related factor relating to such members (or individuals eligible for coverage through a member);   (E) does not make health insurance coverage offered through the association available other than in connection with a member of the association; and   (F) meets such additional requirements as may be imposed under State law.

(4) COBRA CONTINUATION PROVISION. — The term “COBRA continuation provision” means any of the following:   (A) Section 4980B of the Internal Revenue Code of 1986, other than subsection (f)(1) of such section insofar as it relates to pediatric vaccines.   (B) Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, other than section 609 of such Act.   (C) Title XXII of this Act.

(5) EMPLOYEE. — The term “employee” has the meaning given such term under section 3(6) of the Employee Retirement Income Security Act of 1974.

(6) EMPLOYER. — The term “employer” has the meaning given such term under section 3(5) of the Employee Retirement Income Security Act of 1974, except that such term shall include only employers of two or more employees.

(7) CHURCH PLAN. — The term “church plan” has the meaning given such term under section 3(33) of the Employee Retirement Income Security Act of 1974.

(8) GOVERNMENTAL PLAN.  (A) The term “governmental plan” has the meaning given such term under section 3(32) of the Employee Retirement Income Security Act of 1974 and any Federal governmental plan.   (B) FEDERAL GOVERNMENTAL PLAN. — The term “Federal governmental plan” means a governmental plan established or maintained for its employees by the Government of the United States or by any agency or instrumentality of such Government.   (C) NON‑FEDERAL GOVERNMENTAL PLAN. — The term “non‑Federal governmental plan” means a governmental plan that is not a Federal governmental plan.

(9) HEALTH STATUS‑RELATED FACTOR. — The term “health status‑related factor” means any of the factors described in section 2702(a)(1).

(10) NETWORK PLAN. — The term “network plan” means health insurance coverage of a health insurance issuer under which the financing and delivery of medical care (including items and services paid for as medical care) are provided, in whole or in part, through a defined set of providers under contract with the issuer.

(11) PARTICIPANT. — The term “participant” has the meaning given such term under section 3(7) of the Employee Retirement Income Security Act of 1974.

(12) PLACED FOR ADOPTION DEFINED. — The term “placement”, or being “placed”, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement with such person terminates upon the termination of such legal obligation.

(13) PLAN SPONSOR. — The term “plan sponsor” has the meaning given such term under section 3(16)(B) of the Employee Retirement Income Security Act of 1974.

(14) STATE. — The term “State” means each of the several States, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands.

(e) DEFINITIONS RELATING TO MARKETS AND SMALL EMPLOYERS. — For purposes of this title: (1) INDIVIDUAL MARKET.  (A) IN GENERAL. — The term “individual market” means the market for health insurance coverage offered to individuals other than in connection with a group health plan.   (B) TREATMENT OF VERY SMALL GROUPS.    (i) IN GENERAL. — Subject to clause (ii), such terms includes coverage offered in connection with a group health plan that has fewer than two participants as current employees on the first day of the plan year.     (ii) STATE EXCEPTION. — Clause (i) shall not apply in the case of a State that elects to regulate the coverage described in such clause as coverage in the small group market.

(2) LARGE EMPLOYER. — The term “large employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 51 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.

(3) LARGE GROUP MARKET. — The term “large group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer.

(4) SMALL EMPLOYER. — The term “small employer” means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year.

(5) SMALL GROUP MARKET. — The term “small group market” means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a small employer.

(6) APPLICATION OF CERTAIN RULES IN DETERMINATION OF EMPLOYER SIZE. — For purposes of this subsection:   (A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS. — all persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as 1 employer.   (B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR. — In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.   (C) PREDECESSORS. — Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.