PART 144—REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE Authority: 42 U.S.C. 300gg through 300gg-63, 300gg-91, 300gg-92, and 300gg-111 through 300gg-139, as amended. Source: 62 FR 16955, Apr. 8, 1997, unless otherwise noted. Subpart A—General Provisions § 144.101 Basis and purpose. (a) Part 146 of this subchapter implements requirements of Title XXVII of the Public Health Service Act (PHS Act, 42 U.S.C. 300gg, et seq. (b) Part 147 of this subchapter implements the provisions of the Patient Protection and Affordable Care Act that apply to both group health plans and health insurance issuers in the Group and Individual Markets. (c) Part 148 of this subchapter implements Individual Health Insurance Market requirements of the PHS Act. Its purpose is to improve access to individual health insurance coverage for certain individuals who previously had group coverage, guarantee the renewability of all health insurance coverage in the individual market, and provide certain protections for mothers and newborns with respect to coverage for hospital stays in connection with childbirth, and to provide certain protections for patients who elect breast reconstruction in connection with a mastectomy. (d) Part 149 of this subchapter implements the provisions of parts D and E of title XXVII of the PHS Act that apply to group health plans, health insurance issuers in the group and individual markets, health care providers and facilities, and providers of air ambulance services. (e) Part 150 of this subchapter implements the enforcement provisions of sections 2723 and 2761 of the PHS Act with respect to the following: (1) States that fail to substantially enforce one or more provisions of part 146 concerning group health insurance, one or more provisions of part 147 concerning group or individual health insurance, or the requirements of part 148 of this subchapter concerning individual health insurance. (2) Insurance issuers in States described in paragraph (d)(1) of this section. (3) Group health plans that are non-Federal governmental plans. (f) Sections 2791 and 2792 of the PHS Act define terms used in the regulations in this subchapter and provide the basis for issuing these regulations. [64 FR 45795, Aug. 20, 1999, as amended at 74 FR 51688, Oct. 7, 2009; 75 FR 27137, May 13, 2010; 78 FR 13435, Feb. 27, 2013; 86 FR 36970, July 13, 2021] § 144.102 Scope and applicability. (a) For purposes of 45 CFR parts 144 through 149, all health insurance coverage is generally divided into two markets—the group market and the individual market. The group market is further divided into the large group market and the small group market. (b) The protections afforded under 45 CFR parts 144 through 149 to individuals and employers (and other sponsors of health insurance offered in connection with a group health plan) are determined by whether the coverage involved is obtained in the small group market, the large group market, or the individual market. (c) Coverage that is provided to associations, but not related to employment, and sold to individuals is not considered group coverage under 45 CFR parts 144 through 149. If the coverage is offered to an association member other than in connection with a group health plan, the coverage is considered individual health insurance coverage for purposes of 45 CFR parts 144 through 149. The coverage is considered coverage in the individual market, regardless of whether it is considered group coverage under state law. If the health insurance coverage is offered in connection with a group health plan as defined at 45 CFR 144.103, it is considered group health insurance coverage for purposes of 45 CFR parts 144 through 149. (d) Provisions relating to CMS enforcement of parts 146, 147, 148, and 149 are contained in part 150 of this subchapter. [86 FR 36970, July 13, 2021] § 144.103 Definitions. For purposes of parts 146 (group market), 147 (group and individual market), 148 (individual market), 149 (surprise billing and transparency), and 150 (enforcement) of this subchapter, the following definitions apply unless otherwise provided: Affiliation period Applicable State authority Beneficiary Bona fide association (1) Has been actively in existence for at least 5 years. (2) Has been formed and maintained in good faith for purposes other than obtaining insurance. (3) 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 any employee). (4) Makes health insurance coverage offered through the association available to all members regardless of any health status-related factor relating to the members (or individuals eligible for coverage through a member). (5) Does not make health insurance coverage offered through the association available other than in connection with a member of the association. (6) Meets any additional requirements that may be imposed under State law. Church plan COBRA (1) COBRA X (2) COBRA continuation coverage (3) COBRA continuation provision (4) Continuation coverage (5) Exhaustion of COBRA continuation coverage (i) Due to the failure of the employer or other responsible entity to remit premiums on a timely basis; (ii) When the individual no longer resides, lives, or works in the service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other COBRA continuation coverage available to the individual; or (iii) When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other COBRA continuation coverage available to the individual. (6) Exhaustion of continuation coverage (i) Coverage ceases due to the failure of the employer or other responsible entity to remit premiums on a timely basis; (ii) When the individual no longer resides, lives or works in a service area of an HMO or similar program (whether or not within the choice of the individual) and there is no other continuation coverage available to the individual; or (iii) When the individual incurs a claim that would meet or exceed a lifetime limit on all benefits and there is no other continuation coverage available to the individual. Condition medical condition. Creditable coverage Dependent Eligible individual, (1) The group market provisions in 45 CFR part 146, subpart E, is defined in 45 CFR 146.150(b); and (2) The individual market provisions in 45 CFR part 148, is defined in 45 CFR 148.103. Employee Employer Enroll Enrollment date ERISA et seq. Excepted benefits, (1) Group market provisions in 45 CFR part 146, subpart D, is defined in 45 CFR 146.145(b); and (2) Individual market provisions in 45 CFR part 148, is defined in 45 CFR 148.220. Federal governmental plan First day of coverage Genetic information Governmental plan Group health insurance coverage Group health plan plan Group market Health insurance coverage Health insurance issuer issuer Health maintenance organization HMO (1) A Federally qualified health maintenance organization (as defined in section 1301(a) of the PHS Act); (2) An organization recognized under State law as a health maintenance organization; or (3) A similar organization regulated under State law for solvency in the same manner and to the same extent as such a health maintenance organization. Health status-related factor Individual health insurance coverage Individual market Internal Revenue Code Issuer health insurance issuer. Large employer Large group market Late enrollee Late enrollment Medical care (1) The diagnosis, cure, mitigation, treatment, or prevention of disease, or amounts paid for the purpose of affecting any structure or function of the body; (2) Transportation primarily for and essential to medical care referred to in paragraph (1) of this definition; and (3) Insurance covering medical care referred to in paragraphs (1) and (2) of this definition. Medical condition condition Network plan Non-Federal governmental plan Participant PHS Act et seq. Placement, or being placed, for adoption Plan (1) The plan will be considered to be the same plan if it: (i) Has the same cost-sharing structure as before the modification, or any variation in cost sharing is solely related to changes in cost or utilization of medical care, or is to maintain the same metal tier level described in sections 1302(d) and (e) of the Affordable Care Act; (ii) Continues to cover a majority of the same service area; and (iii) Continues to cover a majority of the same provider network. For this purpose, the plan's provider network on the first day of the plan year is compared with the plan's provider network on the first day of the preceding plan year (as applicable). (2) The plan will not fail to be treated as the same plan to the extent the modification(s) are made uniformly and solely pursuant to applicable Federal and State requirements if— (i) The modification is made within a reasonable time period after the imposition or modification of the Federal or State requirement; (ii) The modification is directly related to the imposition or modification of the Federal or State requirement. (3) A State may permit greater changes to the cost-sharing structure, or designate a lower threshold for maintenance of the same provider network or service area for a plan to still be considered the same plan. Plan sponsor Plan year (1) The deductible or limit year used under the plan; (2) If the plan does not impose deductibles or limits on a yearly basis, then the plan year is the policy year; (3) If the plan does not impose deductibles or limits on a yearly basis, and either the plan is not insured or the insurance policy is not renewed on an annual basis, then the plan year is the employer's taxable year; or (4) In any other case, the plan year is the calendar year. Policy year (1) A grandfathered health plan offered in the individual health insurance market and student health insurance coverage, the 12-month period that is designated as the policy year in the policy documents of the health insurance coverage. If there is no designation of a policy year in the policy document (or no such policy document is available), then the policy year is the deductible or limit year used under the coverage. If deductibles or other limits are not imposed on a yearly basis, the policy year is the calendar year. (2) A non-grandfathered health plan offered in the individual health insurance market, or in a market in which the State has merged the individual and small group risk pools, for coverage issued or renewed beginning January 1, 2014, a calendar year for which health insurance coverage provides coverage for health benefits. Preexisting condition exclusion Product Public health plan Short-term, limited-duration insurance (1) Short-term, limited-duration insurance (i) Has an expiration date specified in the policy, certificate, or contract of insurance that is no more than 3 months after the original effective date of the policy, certificate, or contract of insurance, and taking into account any renewals or extensions, has a duration no longer than 4 months in total. For purposes of this paragraph (1)(i), a renewal or extension includes the term of a new short-term, limited-duration insurance policy, certificate, or contract of insurance issued by the same issuer, or if the issuer is a member of a controlled group, any other issuer that is a member of such controlled group, to the same policyholder within the 12-month period beginning on the original effective date of the initial policy, certificate, or contract of insurance; and (ii) Displays prominently on the first page (in either paper or electronic form, including on a website) of the policy, certificate, or contract of insurance, and in any marketing, application, and enrollment materials (including reenrollment materials) provided to individuals at or before the time an individual has the opportunity to enroll (or reenroll) in the coverage, in at least 14-point font, the language in the following notice: (2) For purposes of paragraph (1)(i) of this definition, the term “controlled group” means any group treated as a single employer under section 52(a), 52(b), 414(m), or 414(o) of the Internal Revenue Code of 1986, as amended. (3) If any provision of this definition is held to be invalid or unenforceable by its terms, or as applied to any entity or circumstance, or stayed pending further agency action, the provision shall be construed so as to continue to give the maximum effect to the provision permitted by law, along with other provisions not found invalid or unenforceable, including as applied to entities not similarly situated or to dissimilar circumstances, unless such holding is that the provision is invalid and unenforceable in all circumstances, in which event the provision shall be severable from the remainder of the definition and shall not affect the remainder thereof. Significant break in coverage Small employer Small group market Special enrollment State State health benefits risk pool Student health insurance coverage Travel insurance Waiting period [69 FR 78781, Dec. 30, 2004] Editorial Note: For Federal Register Subpart B—Qualified State Long-Term Care Insurance Partnerships: Reporting Requirements for Insurers Source: 73 FR 76968, Dec. 18, 2008, unless otherwise noted. § 144.200 Basis. This subpart implements— (a) Section 1917(b)(1)(C) (iii)(VI) of the Social Security Act, (Act) which requires the issuer of a long-term care insurance policy issued under a qualified State long-term care insurance partnership to provide specified regular reports to the Secretary. (b) Section 1917(b)(1)(C)(v) of the Act, which specifies that the regulations of the Secretary under section 1917(b)(1)(C)(iii)(VI) of the Act shall be promulgated after consultation with the National Association of Insurance Commissioners, issuers of long-term care insurance policies, States with experience with long-term care insurance partnership plans, other States, and representatives of consumers of long-term care insurance policies, and shall specify the type and format of the data to be reported and the frequency with which such reports are to be made. This section of the statute also provides that the Secretary provide copies of the reports to the States involved. § 144.202 Definitions. As used in this subpart— Partnership qualified policy Qualified long-term care insurance policy Qualified State long-term care insurance partnership § 144.204 Applicability of regulations. The regulations contained in this subpart for reporting data apply only to those insurers that have issued qualified long-term care insurance policies to individuals under a qualified State long-term care insurance partnership. They do not apply to the reporting of data by insurers for States with a Medicaid State plan amendment that established a long-term care partnership on or before May 14, 1993. § 144.206 Reporting requirements. (a) General requirement. (b) Specific requirements. (1) Registry of active individual and group partnership qualified policies or certificates. (A) Any insured individual who held an active partnership qualified policy or certificate at any point during a reporting period, even if the policy or certificate was subsequently cancelled, lost partnership qualified status, or otherwise terminated during the reporting period; and (B) All active group long-term care partnership qualified insurance policies, even if the identity of the individual policy/certificate holder is unavailable. (ii) The data required under paragraph (b)(1)(i) of this section must cover a 6-month reporting period of January through June 30 or July 1 through December 31 of each year; and (iii) The data must include, but are not limited to— (A) Current identifying information on the insured individual; (B) The name of the insurance company and issuing State; (C) The effective date and terms of coverage under the policy. (D) The annual premium. (E) The coverage period. (F) Other information, as specified by the Secretary in “State Long-Term Care Partnership Insurer Reporting Requirements.” (2) Claims paid under partnership qualified policies or certificates. (i) Cover a quarterly reporting period of 3 months; (ii) Include, but are not limited to— (A) Current identifying information on the insured individual; (B) The type and cash amount of the benefits paid during the reporting period and lifetime to date; (C) Remaining lifetime benefits; (D) Other information, as specified by the Secretary in “State Long-Term Care Partnership Insurer Reporting Requirements.” § 144.208 Deadlines for submission of reports. (a) Transition provision for insurers who have issued or exchanged a qualified partnership policy prior to the effective date of these regulations. The first reports required for these insurers will be the reports that pertain to the reporting period that begins no more than 120 days after the effective date of the final regulations. (b) All reports on the registry of qualified long-term care insurance policies issued to individuals or individuals under group coverage specified in § 144.206(b)(1)(ii) must be submitted within 30 days of the end of the 6-month reporting period. (c) All reports on the claims paid under qualified long-term care insurance policies issued to individual and individuals under group coverage specified in § 144.206(b)(2)(i) must be submitted within 30 days of the end of the 3-month quarterly reporting period. § 144.210 Form and manner of reports. All reports specified in § 144.206 must be submitted in the form and manner specified by the Secretary. § 144.212 Confidentiality of information. Data collected and reported under the requirements of this subpart are subject to the confidentiality of information requirements specified in regulations under 42 CFR part 401, subpart B, and 45 CFR part 5, subpart F. § 144.214 Notifications of noncompliance with reporting requirements. If an insurer of a qualified long-term care insurance policy does not submit the required reports by the due dates specified in this subpart, the Secretary notifies the appropriate State insurance commissioner within 45 days after the deadline for submission of the information and data specified in § 144.208.