Collapse to view only § 18021. Qualified health plan defined
- § 18021. Qualified health plan defined
- § 18022. Essential health benefits requirements
- § 18023. Special rules
- § 18024. Related definitions
§ 18021. Qualified health plan defined
(a) Qualified health planIn this title: 1
1 See References in Text note below.
(1) In generalThe term “qualified health plan” means a health plan that—
(A) has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 18031(c) of this title issued or recognized by each Exchange through which such plan is offered;
(B) provides the essential health benefits package described in section 18022(a) of this title; and
(C) is offered by a health insurance issuer that—
(i) is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title; 1
(ii) agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange;
(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and
(iv) complies with the regulations developed by the Secretary under section 18031(d) of this title and such other requirements as an applicable Exchange may establish.
(2) Inclusion of CO–OP plans and multi-State qualified health plans
(3) Treatment of qualified direct primary care medical home plans
(4) Variation based on rating area
(b) Terms relating to health plansIn this title: 1
(1) Health plan
(A) In general
(B) Exception for self-insured plans and MEWAs
(2) Health insurance coverage and issuer
(3) Group health plan
(Pub. L. 111–148, title I, § 1301, title X, § 10104(a), Mar. 23, 2010, 124 Stat. 162, 896.)
§ 18022. Essential health benefits requirements
(a) Essential health benefits packageIn this title,1
1 See References in Text note below.
the term “essential health benefits package” means, with respect to any health plan, coverage that—(1) provides for the essential health benefits defined by the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance with subsection (c); and
(3) subject to subsection (e), provides either the bronze, silver, gold, or platispan level of coverage described in subsection (d).
(b) Essential health benefits
(1) In generalSubject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services, including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease management.
(J) Pediatric services, including oral and vision care.
(2) Limitation
(A) In general
(B) Certification
(3) Notice and hearing
(4) Required elements for considerationIn defining the essential health benefits under paragraph (1), the Secretary shall—
(A) ensure that such essential health benefits reflect an appropriate balance among the categories described in such subsection,2
2 So in original. Probably should be “paragraph,”.
so that benefits are not unduly weighted toward any category;(B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;
(C) take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;
(D) ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals’ age or expected length of life or of the individuals’ present or predicted disability, degree of medical dependency, or quality of life;
(E) provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits described in paragraph (1) unless the plan provides that—
(i) coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and
(ii) if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;
(F) provide that if a plan described in section 18031(b)(2)(B)(ii) 3
3 So in original. Probably should be “18031(d)(2)(B)(ii)”.
of this title (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1)(J); and 44 So in original. The word “and” probably should not appear.
(G) periodically review the essential health benefits under paragraph (1), and provide a report to Congress and the public that contains—
(i) an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;
(ii) an assessment of whether the essential health benefits needs to be modified or updated to account for changes in medical evidence or scientific advancement;
(iii) information on how the essential health benefits will be modified to address any such gaps in access or changes in the evidence base;
(iv) an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in paragraph (2); and
(H) periodically update the essential health benefits under paragraph (1) to address any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under subparagraph (G).
(5) Rule of construction
(c) Requirements relating to cost-sharing
(1) Annual limitation on cost-sharing
(A) 2014
(B) 2015 and laterIn the case of any plan year beginning in a calendar year after 2014, the limitation under this paragraph shall—
(i) in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and
(ii) in the case of other coverage, twice the amount in effect under clause (i).
If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
(2) Repealed. Pub. L. 113–93, title II, § 213(a)(1), Apr. 1, 2014, 128 Stat. 1047
(3) Cost-sharingIn this title— 1
(A) In generalThe term “cost-sharing” includes—
(i) deductibles, coinsurance, copayments, or similar charges; and
(ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of title 26) with respect to essential health benefits covered under the plan.
(B) Exceptions
(4) Premium adjustment percentage
(d) Levels of coverage
(1) Levels of coverage definedThe levels of coverage described in this subsection are as follows:
(A) Bronze level
(B) Silver level
(C) Gold level
(D) Platispan level
(2) Actuarial value
(A) In general
(B) Employer contributions
(C) Application
(3) Allowable variance
(4) Plan reference
(e) Catastrophic plan
(1) In generalA health plan not providing a bronze, silver, gold, or platispan level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if—
(A) the only individuals who are eligible to enroll in the plan are individuals described in paragraph (2); and
(B) the plan provides—
(i) except as provided in clause (ii), the essential health benefits determined under subsection (b), except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) for the plan year (except as provided for in section 2713); 1 and
(ii) coverage for at least three primary care visits.
(2) Individuals eligible for enrollmentAn individual is described in this paragraph for any plan year if the individual—
(A) has not attained the age of 30 before the beginning of the plan year; or
(B) has a certification in effect for any plan year under this title 1 that the individual is exempt from the requirement under section 5000A of title 26 by reason of—
(i) section 5000A(e)(1) of such title (relating to individuals without affordable coverage); or
(ii) section 5000A(e)(5) of such title (relating to individuals with hardships).
(3) Restriction to individual market
(f) Child-only plans
(g) Payments to Federally-qualified health centers
(Pub. L. 111–148, title I, § 1302, title X, § 10104(b), Mar. 23, 2010, 124 Stat. 163, 896; Pub. L. 113–93, title II, § 213(a), Apr. 1, 2014, 128 Stat. 1047.)
§ 18023. Special rules
(a) State opt-out of abortion coverage
(1) In general
(2) Termination of opt out
(b)
(1) Voluntary choice of coverage of abortion services
(A) In generalNotwithstanding any other provision of this title 1
1 See References in Text note below.
(or any amendment made by this title)— 1(i) nothing in this title 1 (or any amendment made by this title),1 shall be construed to require a qualified health plan to provide coverage of services described in subparagraph (B)(i) or (B)(ii) as part of its essential health benefits for any plan year; and
(ii) subject to subsection (a), the issuer of a qualified health plan shall determine whether or not the plan provides coverage of services described in subparagraph (B)(i) or (B)(ii) as part of such benefits for the plan year.
(B) Abortion services
(i) Abortions for which public funding is prohibited
(ii) Abortions for which public funding is allowed
(2) Prohibition on the use of Federal funds
(A) In generalIf a qualified health plan provides coverage of services described in paragraph (1)(B)(i), the issuer of the plan shall not use any amount attributable to any of the following for purposes of paying for such services:
(i) The credit under section 36B of title 26 (and the amount (if any) of the advance payment of the credit under section 18082 of this title).
(ii) Any cost-sharing reduction under section 18071 of this title (and the amount (if any) of the advance payment of the reduction under section 18082 of this title).
(B) Establishment of allocation accountsIn the case of a plan to which subparagraph (A) applies, the issuer of the plan shall—
(i) collect from each enrollee in the plan (without regard to the enrollee’s age, sex, or family status) a separate payment for each of the following:(I) an amount equal to the portion of the premium to be paid directly by the enrollee for coverage under the plan of services other than services described in paragraph (1)(B)(i) (after reduction for credits and cost-sharing reductions described in subparagraph (A)); and(II) an amount equal to the actuarial value of the coverage of services described in paragraph (1)(B)(i), and
(ii) shall 2
2 So in original. The word “shall” probably should not appear.
deposit all such separate payments into separate allocation accounts as provided in subparagraph (C).In the case of an enrollee whose premium for coverage under the plan is paid through employee payroll deposit, the separate payments required under this subparagraph shall each be paid by a separate deposit.
(C) Segregation of funds
(i) In general
(ii) Allocation accountsThe issuer of a plan to which subparagraph (A) applies shall deposit—(I) all payments described in subparagraph (B)(i)(I) into a separate account that consists solely of such payments and that is used exclusively to pay for services other than services described in paragraph (1)(B)(i); and(II) all payments described in subparagraph (B)(i)(II) into a separate account that consists solely of such payments and that is used exclusively to pay for services described in paragraph (1)(B)(i).
(D) Actuarial value
(i) In general
(ii) ConsiderationsIn making such estimate, the issuer—(I) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care;(II) shall estimate such costs as if such coverage were included for the entire population covered; and(III) may not estimate such a cost at less than $1 per enrollee, per month.
(E) Ensuring compliance with segregation requirements
(i) In general
(ii) Clarification
(3) Rules relating to notice
(A) Notice
(B) Rules relating to payments
(4) No discrimination on basis of provision of abortion
(c) Application of State and Federal laws regarding abortion
(1) No preemption of State laws regarding abortion
(2) No effect on Federal laws regarding abortion
(A)4
4 So in original. There is no subpar. (B).
In generalNothing in this Act shall be construed to have any effect on Federal laws regarding—(i) conscience protection;
(ii) willingness or refusal to provide abortion; and
(iii) discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.
(3) No effect on Federal civil rights law
(d) Application of emergency services laws
(Pub. L. 111–148, title I, § 1303, title X, § 10104(c), Mar. 23, 2010, 124 Stat. 168, 896.)
§ 18024. Related definitions
(a) Definitions relating to markets
In this title: 1
1 See References in Text note below.
(1) Group market
(2) Individual market
(3) Large and small group markets
(b) Employers
In this title: 1
(1) Large employer
(2) Small employer
(3) State option to extend definition of small employer
(4) Rules for determining employer size
For purposes of this subsection—
(A) Application of aggregation rule for employers
(B) Employers not in existence in preceding year
(C) Predecessors
(D) Continuation of participation for growing small employers
If—
(i) a qualified employer that is a small employer makes enrollment in qualified health plans offered in the small group market available to its employees through an Exchange; and
(ii) the employer ceases to be a small employer by reason of an increase in the number of employees of such employer;
the employer shall continue to be treated as a small employer for purposes of this subchapter for the period beginning with the increase and ending with the first day on which the employer does not make such enrollment available to its employees.
(c) Secretary
(d) State
(e) Educated health care consumers
(Pub. L. 111–148, title I, § 1304, title X, § 10104(d), Mar. 23, 2010, 124 Stat. 171, 900; Pub. L. 114–60, § 2(a), Oct. 7, 2015, 129 Stat. 543.)