Collapse to view only § 18063. Risk adjustment
- § 18061. Transitional reinsurance program for individual market in each State
- § 18062. Establishment of risk corridors for plans in individual and small group markets
- § 18063. Risk adjustment
§ 18061. Transitional reinsurance program for individual market in each State
(a) In general
Each State shall, not later than January 1, 2014—
(1) include in the Federal standards or State law or regulation the State adopts and has in effect under section 18041(b) of this title the provisions described in subsection (b); and
(2) establish (or enter into a contract with) 1 or more applicable reinsurance entities to carry out the reinsurance program under this section.
(b) Model regulation
(1) In general
In establishing the Federal standards under section 18041(a) of this title, the Secretary, in consultation with the National Association of Insurance Commissioners (the “NAIC”), shall include provisions that enable States to establish and maintain a program under which—
(A) health insurance issuers, and third party administrators on behalf of group health plans, are required to make payments to an applicable reinsurance entity for any plan year beginning in the 3-year period beginning January 1, 2014 (as specified in paragraph (3); 1
1 So in original. A second closing parenthesis probably should precede the semicolon.
and(B) the applicable reinsurance entity collects payments under subparagraph (A) and uses amounts so collected to make reinsurance payments to health insurance issuers described in subparagraph (A) that cover high risk individuals in the individual market (excluding grandfathered health plans) for any plan year beginning in such 3-year period.
(2) High-risk individual; payment amounts
The Secretary shall include the following in the provisions under paragraph (1):
(A) Determination of high-risk individuals
The method by which individuals will be identified as high risk individuals for purposes of the reinsurance program established under this section. Such method shall provide for identification of individuals as high-risk individuals on the basis of—
(i) a list of at least 50 but not more than 100 medical conditions that are identified as high-risk conditions and that may be based on the identification of diagnostic and procedure codes that are indicative of individuals with pre-existing, high-risk conditions; or
(ii) any other comparable objective method of identification recommended by the American Academy of Actuaries.
(B) Payment amount
The formula for determining the amount of payments that will be paid to health insurance issuers described in paragraph (1)(B) that insure high-risk individuals. Such formula shall provide for the equitable allocation of available funds through reconciliation and may be designed—
(i) to provide a schedule of payments that specifies the amount that will be paid for each of the conditions identified under subparagraph (A); or
(ii) to use any other comparable method for determining payment amounts that is recommended by the American Academy of Actuaries and that encourages the use of care coordination and care management programs for high risk conditions.
(3) Determination of required contributions
(A) In general
(B) Specific requirements
The method under this paragraph shall be designed so that—
(i) the contribution amount for each issuer proportionally reflects each issuer’s fully insured commercial book of business for all major medical products and the total value of all fees charged by the issuer and the costs of coverage administered by the issuer as a third party administrator;
(ii) the contribution amount can include an additional amount to fund the administrative expenses of the applicable reinsurance entity;
(iii) the aggregate contribution amounts for all States shall, based on the best estimates of the NAIC and without regard to amounts described in clause (ii), equal $10,000,000,000 for plan years beginning in 2014, $6,000,000,000 for plan years beginning 2
2 So in original. Probably should be followed by “in”.
2015, and $4,000,000,000 for plan years beginning in 2016; and(iv) in addition to the aggregate contribution amounts under clause (iii), each issuer’s contribution amount for any calendar year under clause (iii) reflects its proportionate share of an additional $2,000,000,000 for 2014, an additional $2,000,000,000 for 2015, and an additional $1,000,000,000 for 2016.
Nothing in this subparagraph shall be construed to preclude a State from collecting additional amounts from issuers on a voluntary basis.
(4) Expenditure of funds
The provisions under paragraph (1) shall provide that—
(A) the contribution amounts collected for any calendar year may be allocated and used in any of the three calendar years for which amounts are collected based on the reinsurance needs of a particular period or to reflect experience in a prior period; and
(B) amounts remaining unexpended as of December, 2016, may be used to make payments under any reinsurance program of a State in the individual market in effect in the 2-year period beginning on January 1, 2017.
Notwithstanding the preceding sentence, any contribution amounts described in paragraph (3)(B)(iv) shall be deposited into the general fund of the Treasury of the United States and may not be used for the program established under this section.
(c) Applicable reinsurance entity
For purposes of this section—
(1) In general
The term “applicable reinsurance entity” means a not-for-profit organization—
(A) the purpose of which is to help stabilize premiums for coverage in the individual market in a State during the first 3 years of operation of an Exchange for such markets within the State when the risk of adverse selection related to new rating rules and market changes is greatest; and
(B) the duties of which shall be to carry out the reinsurance program under this section by coordinating the funding and operation of the risk-spreading mechanisms designed to implement the reinsurance program.
(2) State discretion
(3) Entities are tax-exempt
(d) Coordination with State high-risk pools
(Pub. L. 111–148, title I, § 1341, title X, § 10104(r), Mar. 23, 2010, 124 Stat. 208, 906.)
§ 18062. Establishment of risk corridors for plans in individual and small group markets
(a) In general
(b) Payment methodology
(1) Payments out
The Secretary shall provide under the program established under subsection (a) that if—
(A) a participating plan’s allowable costs for any plan year are more than 103 percent but not more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to 50 percent of the target amount in excess of 103 percent of the target amount; and
(B) a participating plan’s allowable costs for any plan year are more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount.
(2) Payments in
The Secretary shall provide under the program established under subsection (a) that if—
(A) a participating plan’s allowable costs for any plan year are less than 97 percent but not less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to 50 percent of the excess of 97 percent of the target amount over the allowable costs; and
(B) a participating plan’s allowable costs for any plan year are less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs.
(c) Definitions
In this section:
(1) Allowable costs
(A) In general
(B) Reduction for risk adjustment and reinsurance payments
(2) Target amount
(Pub. L. 111–148, title I, § 1342, Mar. 23, 2010, 124 Stat. 211.)
§ 18063. Risk adjustment
(a) In general
(1) Low actuarial risk plans
(2) High actuarial risk plans
(b) Criteria and methods
(c) Scope
(Pub. L. 111–148, title I, § 1343, Mar. 23, 2010, 124 Stat. 212.)