Sec. 45. Exclusion of certain plans.

851 words·~4 min read·/il/chapter-215/act-97/45

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(A)Exception for certain small group health plans. The requirements of this Act shall not apply to any group health plan (and 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)Limitation on application of provisions relating to group health plans.

(1)In general. The requirements of this Act shall apply with respect to group health

plans only:

(a)subject to paragraph (2), in the case of a plan that is a nonfederal

governmental plan; and

(b)with respect to health insurance coverage offered in connection with a group

health plan (including such a plan that is a church plan or a governmental plan).

(2)Treatment of nonfederal governmental plans.

(a)Election to be excluded. If the plan sponsor of a nonfederal governmental plan

which is a group health plan to which the provisions of this Act otherwise apply makes an election under this subparagraph (in such form and manner as may be prescribed by rule), then the requirements of this Act insofar as they apply directly to group health plans (and not merely to group health insurance coverage) shall not apply to such governmental plans for such period except as provided in this paragraph.

(b)Period of election. An election under subparagraph

(a)shall apply:

(i)for a single specified plan year; or

(ii)in the case of a plan provided pursuant to a collective bargaining

agreement, for the term of such agreement.

An election under clause

(i)may be extended through subsequent elections under this

paragraph.

(c)Notice to enrollees. Under such an election, the plan shall provide for:

(i)notice to enrollees (on an annual basis and at the time of enrollment under

the plan) of the fact and consequences of such election; and

(ii)certification and disclosure of creditable coverage under the plan with

respect to enrollees in accordance with Section 20(E).

(C)Exception for certain benefits. The requirements of this Act shall not apply to any group health plan (or group health insurance coverage) in relation to its provision of excepted benefits described in Section 20(C)(2)(a).

(D)Exception for certain benefits if certain conditions met.

(1)Limited, excepted benefits. The requirements of this Act 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 20(C)(2)(b) 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 Act 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 20(C)(2)(c) 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 Act shall not apply to any

group health plan (and group health insurance coverage) in relation to its provision of excepted benefits described in Section 20(C)(2)(d) if the benefits are provided under a separate policy, certificate, or contract of insurance.

(E)Treatment of partnerships. For purposes of this Act:

(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)Partnerships 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 the individual's beneficiaries may be eligible for any benefit.