I.R.C. § 9813(a) Medically Necessary Leave Of Absence —
In this section, the term “medically necessary leave of absence” means, with respect
to a dependent child described in subsection (b)(2) in connection with a group health plan, a leave of absence of such child from a postsecondary
educational institution (including an institution of higher education as defined in
section 102 of the Higher Education Act of 1965), or any other change in enrollment of such child
at such an institution, that—
I.R.C. § 9813(a)(1) —
commences while such child is suffering from a serious illness or injury;
I.R.C. § 9813(a)(2) —
is medically necessary; and
I.R.C. § 9813(a)(3) —
causes such child to lose student status for purposes of coverage under the terms
of the plan or coverage.
I.R.C. § 9813(b) Requirement To Continue Coverage
I.R.C. § 9813(b)(1) In General —
In the case of a dependent child described in paragraph (2), a group health plan shall not terminate coverage of such child under such plan due
to a medically necessary leave of absence before the date that is the earlier of—
I.R.C. § 9813(b)(1)(A) —
the date that is 1 year after the first day of the medically necessary leave of absence;
or
I.R.C. § 9813(b)(1)(B) —
the date on which such coverage would otherwise terminate under the terms of the plan.
I.R.C. § 9813(b)(2) Dependent Child Described —
A dependent child described in this paragraph is, with respect to a group health plan,
a beneficiary under the plan who—
I.R.C. § 9813(b)(2)(A) —
is a dependent child, under the terms of the plan, of a participant or beneficiary
under the plan; and
I.R.C. § 9813(b)(2)(B) —
was enrolled in the plan, on the basis of being a student at a postsecondary educational
institution
(as described in subsection (a)), immediately before the first day of the medically
necessary leave of absence involved.
I.R.C. § 9813(b)(3) Certification By Physician —
Paragraph (1) shall apply to a group health plan only if the plan, or the issuer of health insurance
coverage offered in connection with the plan, has received written certification by
a treating physician of the dependent child which states that the child is suffering
from a serious illness or injury and that the leave of absence (or other change of
enrollment)
described in subsection (a) is medically necessary.
I.R.C. § 9813(c) Notice —
A group health plan shall include, with any notice regarding a requirement for certification
of student status for coverage under the plan, a description of the terms of this
section for continued coverage during medically necessary leaves of absence. Such
description shall be in language which is understandable to the typical plan participant.
I.R.C. § 9813(d) No Change In Benefits —
A dependent child whose benefits are continued under this section shall be entitled
to the same benefits as if (during the medically necessary leave of absence) the child
continued to be a covered student at the institution of higher education and was not
on a medically necessary leave of absence.
I.R.C. § 9813(e) Continued Application In Case Of Changed Coverage —
If—
I.R.C. § 9813(e)(1) —
a dependent child of a participant or beneficiary is in a period of coverage under
a group health plan, pursuant to a medically necessary leave of absence of the child
described in subsection (b);
I.R.C. § 9813(e)(2) —
the manner in which the participant or beneficiary is covered under the plan changes,
whether through a change in health insurance coverage or health insurance issuer,
a change between health insurance coverage and self-insured coverage, or otherwise;
and
I.R.C. § 9813(e)(3) —
the coverage as so changed continues to provide coverage of beneficiaries as dependent
children,
this section shall apply to coverage of the child under the changed coverage for the
remainder of the period of the medically necessary leave of absence of the dependent
child under the plan in the same manner as it would have applied if the changed coverage
had been the previous coverage.
(Added by Pub. L. 110-381, Sec. 2(c), Oct. 9, 2008, 122 Stat. 4081.)
BACKGROUND NOTES
EFFECTIVE DATE
Effective with respect to plan years beginning on or after the date that is one year
after the date of the enactment of this Act [Enacted: Oct. 9, 2008] and to medically
necessary leaves of absence beginning during such plan years.
COVERAGE OF TESTING FOR COVID–19
Section 6001 of Pub. L. 116-127 provided:
“SEC. 6001. COVERAGE OF TESTING FOR COVID–19.
“(a) IN GENERAL.—A group health plan and a health insurance issuer offering group
or individual health insurance coverage (including a grandfathered health plan (as
defined in section 1251(e) of the Patient Protection and Affordable Care Act)) shall provide coverage, and shall not impose any cost sharing (including deductibles,
copayments, and coinsurance) requirements or prior authorization or other medical
management requirements, for the following items and services furnished during any
portion of the emergency period defined in paragraph (1)(B)
of section 1135(g) of the Social Security Act (42 U.S.C. 1320b–5(g))
beginning on or after the date of the enactment of this Act:
“(1) In vitro diagnostic products (as defined in section 809.3(a) of title 21, Code
of Federal Regulations) for the detection of SARS–CoV–2 or the diagnosis of the virus
that causes COVID–19 that are approved, cleared, or authorized under section 510(k),
513, 515 or 564 of the Federal Food, Drug, and Cosmetic Act, and the administration
of such in vitro diagnostic products.
“(2) Items and services furnished to an individual during health care provider office
visits (which term in this paragraph includes in-person visits and telehealth visits),
urgent care center visits, and emergency room visits that result in an order for or
administration of an in vitro diagnostic product described in paragraph (1), but only
to the extent such items and services relate to the furnishing or administration of
such product or to the evaluation of such individual for purposes of determining the
need of such individual for such product.
“(b) ENFORCEMENT.—The provisions of subsection (a) shall be applied by the Secretary
of Health and Human Services, Secretary of Labor, and Secretary of the Treasury to
group health plans and health insurance issuers offering group or individual health
insurance coverage as if included in the provisions of part A of title XXVII of the
Public Health Service Act, part 7 of the Employee Retirement Income Security Act of
1974, and subchapter B of chapter100 of the Internal Revenue Code of 1986, as applicable.
“(c) IMPLEMENTATION.—The Secretary of Health and Human Services, Secretary of Labor,
and Secretary of the Treasury may implement the provisions of this section through
sub-regulatory guidance, program instruction or otherwise.
“(d) TERMS.—The terms ‘‘group health plan’’; ‘‘health insurance issuer’’; ‘‘group
health insurance coverage’’, and ‘‘individual health insurance coverage’’ have the
meanings given such terms in section 2791 of the Public Health Service Act (42 U.S.C. 300gg–91), section 733 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1191b), and section 9832 of the Internal Revenue Code of 1986, as applicable.”
