[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR411.101] [Page 318-319] TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE PAYMENT--Table of Contents Subpart E--Limitations on Payment for Services Covered Under Group Health Plans: General Provisions Sec. 411.101 Definitions. As used in this subpart and in subparts F through H of this part-- COBRA stands for Consolidated Omnibus Budget Reconciliation Act of 1985. Days means calendar days. Employee (subject to the special rules in Sec. 411.104) means an individual who-- (1) Is working for an employer; or (2) Is not working for an employer but is receiving payments that are subject to FICA taxes, or would be subject to FICA taxes except that the employer is exempt from those taxes under the Internal Revenue Code. Employer means, in addition to individuals (including self-employed persons) and organizations engaged in a trade or business, other entities exempt from income tax such as religious, charitable, and educational institutions, the governments of the United States, the individual States, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, and the District of Columbia, and the agencies, instrumentalities, and political subdivisions of these governments. FICA stands for the Federal Insurance Contributions Act, the law that imposes social security taxes on employers and employees under section 21 of the Internal Revenue Code. Group health plan (GHP) means any arrangement made by one or more employers or employee organizations to provide health care directly or through other methods such as insurance or reimbursement, to current or former employees, the employer, others associated or formerly associated with the employer in a business relationship, or their families, that-- (1) Is of, or contributed to by, one or more employers or employee organizations. (2) If it involves more than one employer or employee organization, provides for common administration. (3) Provides substantially the same benefits or the same benefit options to [[Page 319]] all those enrolled under the arrangement. The term includes self-insured plans, plans of governmental entities (Federal, State and local), and employee organization plans; that is, union plans, employee health and welfare funds or other employee organization plans. The term also includes employee-pay-all plans, which are plans under the auspices of one or more employers or employee organizations but which receive no financial contributions from them. The term does not include a plan that is unavailable to employees; for example, a plan only for self-employed persons. IRC stands for Internal Revenue Code. IRS stands for Internal Revenue Service. Large group health plan (LGHP) means a GHP that covers employees of either-- (1) A single employer or employee organization that employed at least 100 full-time or part-time employees on 50 percent or more of its regular business days during the previous calendar year; or (2) Two or more employers, or employee organizations, at least one of which employed at least 100 full-time or part-time employees on 50 percent or more of its regular business days during the previous calendar year. MSP stands for Medicare secondary payer. Multi-employer plan means a plan that is sponsored jointly by two or more employers (sometimes called a multiple-employer plan) or by employers and unions (sometimes under the Taft-Hartley law). Self-employed person encompasses consultants, owners of businesses, and directors of corporations, and members of the clergy and religious orders who are paid for their services by a religious body or other entity. Similarly situated individual means-- (1) In the case of employees, other employees enrolled or seeking to enroll in the plan; and (2) In the case of other categories of individuals, other persons in any of those categories who are enrolled or seeking to enroll in the plan.