42 USC 300gg-4 - Prohibiting discrimination against individual participants and beneficiaries based on health status

U.S Code last checked for updates: Nov 22, 2024

§ 300gg–4.

Prohibiting discrimination against individual participants and beneficiaries based on health status

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

(1)

Health status.

(2)

Medical condition (including both physical and mental illnesses).

(3)

Claims experience.

(4)

Receipt of health care.

(5)

Medical history.

(6)

Genetic information.

(7)

Evidence of insurability (including conditions arising out of acts of domestic violence).

(8)

Disability.

(9)

Any other health status-related factor determined appropriate by the Secretary.

(b)

In premium contributions

(1)

In general

(2)

Construction

Nothing in paragraph (1) shall be construed—

(A)

to restrict the amount that an employer or individual may be charged for coverage under a group health plan except as provided in paragraph (3) or individual health coverage, as the case may be; or

(B)

to prevent a group health plan, and a health insurance issuer offering group health insurance coverage, from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

(3)

No group-based discrimination on basis of genetic information

(A)

In general

(B)

Rule of construction

(c)

Genetic testing

(1)

Limitation on requesting or requiring genetic testing

(2)

Rule of construction

(3)

Rule of construction regarding payment

(A)

In general

(B)

Limitation

(4)

Research exception

Notwithstanding paragraph (1), a group health plan, or a health insurance issuer offering health insurance coverage in connection with a group health plan, may request, but not require, that a participant or beneficiary undergo a genetic test if each of the following conditions is met:

(A)

The request is made pursuant to research that complies with part 46 of title 45, Code of Federal Regulations, or equivalent Federal regulations, and any applicable State or local law or regulations for the protection of human subjects in research.

(B)

The plan or issuer clearly indicates to each participant or beneficiary, or in the case of a minor child, to the legal guardian of such beneficiary, to whom the request is made that—

(i)

compliance with the request is voluntary; and

(ii)

non-compliance will have no effect on enrollment status or premium or contribution amounts.

(C)

No genetic information collected or acquired under this paragraph shall be used for underwriting purposes.

(D)

The plan or issuer notifies the Secretary in writing that the plan or issuer is conducting activities pursuant to the exception provided for under this paragraph, including a description of the activities conducted.

(E)

The plan or issuer complies with such other conditions as the Secretary may by regulation require for activities conducted under this paragraph.

(d)

Prohibition on collection of genetic information

(1)

In general

(2)

Prohibition on collection of genetic information prior to enrollment

(3)

Incidental collection

(e)

Application to all plans

(f)

Genetic information of a fetus or embryo

Any reference in this part to genetic information concerning an individual or family member of an individual shall—

(1)

with respect to such an individual or family member of an individual who is a pregnant woman, include genetic information of any fetus carried by such pregnant woman; and

(2)

with respect to an individual or family member utilizing an assisted reproductive technology, include genetic information of any embryo legally held by the individual or family member.

(j)

 So in original. No subsecs. (g) to (i) have been enacted.

Programs of health promotion or disease prevention

(1)

General provisions

(A)

General rule

(B)

No conditions based on health status factor

(C)

Conditions based on health status factor

(2)

Wellness programs not subject to requirements

(A)

A program that reimburses all or part of the cost for memberships in a fitness center.

(B)

A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes.

(C)

A program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under group ¹ health plan for the costs of certain items or services related to a health condition (such as prenatal care or well-baby visits).

(D)

A program that reimburses individuals for the costs of smoking cessation programs without regard to whether the individual quits smoking.

(E)

A program that provides a reward to individuals for attending a periodic health education seminar.

(3)

Wellness programs subject to requirements

If any of the conditions for obtaining a premium discount, rebate, or reward under a wellness program as described in paragraph (1)(C) is based on an individual satisfying a standard that is related to a health status factor, the wellness program shall not violate this section if the following requirements are complied with:

(A)

The reward for the wellness program, together with the reward for other wellness programs with respect to the plan that requires satisfaction of a standard related to a health status factor, shall not exceed 30 percent of the cost of employee-only coverage under the plan. If, in addition to employees or individuals, any class of dependents (such as spouses or spouses and dependent children) may participate fully in the wellness program, such reward shall not exceed 30 percent of the cost of the coverage in which an employee or individual and any dependents are enrolled. For purposes of this paragraph, the cost of coverage shall be determined based on the total amount of employer and employee contributions for the benefit package under which the employee is (or the employee and any dependents are) receiving coverage. A reward may be in the form of a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as deductibles, copayments, or coinsurance), the absence of a surcharge, or the value of a benefit that would otherwise not be provided under the plan. The Secretaries of Labor, Health and Human Services, and the Treasury may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage if the Secretaries determine that such an increase is appropriate.

(B)

The wellness program shall be reasonably designed to promote health or prevent disease. A program complies with the preceding sentence if the program has a reasonable chance of improving the health of, or preventing disease in, participating individuals and it is not overly burdensome, is not a subterfuge for discriminating based on a health status factor, and is not highly suspect in the method chosen to promote health or prevent disease.

(C)

The plan shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once each year.

(D)

The full reward under the wellness program shall be made available to all similarly situated individuals. For such purpose, among other things:

(i)

The reward is not available to all similarly situated individuals for a period unless the wellness program allows—

(I)

for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; and

(II)

for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard.

(ii)

If reasonable under the circumstances, the plan or issuer may seek verification, such as a statement from an individual’s physician, that a health status factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.

(E)

The plan or issuer involved shall disclose in all plan materials describing the terms of the wellness program the availability of a reasonable alternative standard (or the possibility of waiver of the otherwise applicable standard) required under subparagraph (D). If plan materials disclose that such a program is available, without describing its terms, the disclosure under this subparagraph shall not be required.

(k)

Existing programs

(l)

Wellness program demonstration project

(1)

In general

(2)

Expansion of demonstration project

(3)

Requirements

(A)

Maintenance of coverage

The Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall not approve the participation of a State in the demonstration project under this section unless the Secretaries determine that the State’s project is designed in a manner that—

(i)

will not result in any decrease in coverage; and

(ii)

will not increase the cost to the Federal Government in providing credits under section 36B of title 26 or cost-sharing assistance under section 18071 of this title.

(B)

Other requirements

States that participate in the demonstration project under this subsection—

(i)

may permit premium discounts or rebates or the modification of otherwise applicable copayments or deductibles for adherence to, or participation in, a reasonably designed program of health promotion and disease prevention;

(ii)

shall ensure that requirements of consumer protection are met in programs of health promotion in the individual market;

(iii)

shall require verification from health insurance issuers that offer health insurance coverage in the individual market of such State that premium discounts—

(I)

do not create undue burdens for individuals insured in the individual market;

(II)

do not lead to cost shifting; and

(III)

are not a subterfuge for discrimination;

(iv)

shall ensure that consumer data is protected in accordance with the requirements of section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note); and

(v)

shall ensure and demonstrate to the satisfaction of the Secretary that the discounts or other rewards provided under the project reflect the expected level of participation in the wellness program involved and the anticipated effect the program will have on utilization or medical claim costs.

(m)

Report

(1)

In general

Not later than 3 years after March 23, 2010, the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall submit a report to the appropriate committees of Congress concerning—

(A)

the effectiveness of wellness programs (as defined in subsection (j)) in promoting health and preventing disease;

(B)

the impact of such wellness programs on the access to care and affordability of coverage for participants and non-participants of such programs;

(C)

the impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior; and

(D)

the effectiveness of different types of rewards.

(2)

Data collection

(n)

Regulations

(July 1, 1944, ch. 373, title XXVII, § 2705, as added and amended Pub. L. 111–148, title I, § 1201(3), (4), Mar. 23, 2010, 124 Stat. 154, 156.)

cite as: 42 USC 300gg-4