42 USC 18012 - Rating reforms must apply uniformly to all health insurance issuers and group health plans

Collapse to view only § 18012. Rating reforms must apply uniformly to all health insurance issuers and group health plans

§ 18011. Preservation of right to maintain existing coverage
§ 18012. Rating reforms must apply uniformly to all health insurance issuers and group health plans
§ 18013. Annual report on self-insured plans
§ 18014. Treatment of expatriate health plans under ACA

§ 18011. Preservation of right to maintain existing coverage

(a) No changes to existing coverage

(1) In general

(2) Continuation of coverage

(3) Application of certain provisions

(4) Application of certain provisions

(A) In general

The following provisions of the Public Health Service Act [42 U.S.C. 201 et seq.] (as added by this title) 1

1 See References in Text note below.

shall apply to grandfathered health plans for plan years beginning with the first plan year to which such provisions would otherwise apply:

(i) Section 2708 [42 U.S.C. 300gg–7] (relating to excessive waiting periods).

(ii) Those provisions of section 2711 [42 U.S.C. 300gg–11] relating to lifetime limits.

(iii) Section 2712 [42 U.S.C. 300gg–12] (relating to rescissions).

(iv) Section 2714 [42 U.S.C. 300gg–14] (relating to extension of dependent coverage).

(B) Provisions applicable only to group health plans

(i) Provisions described

(ii) Adult child coverage

(5) Application of additional provisions

(b) Allowance for family members to join current coverage

(d) Effect on collective bargaining agreements

(e) Definition

(Pub. L. 111–148, title I, § 1251, title X, § 10103(d), Mar. 23, 2010, 124 Stat. 161, 895; Pub. L. 111–152, title II, § 2301(a), Mar. 30, 2010, 124 Stat. 1081; Pub. L. 116–260, div. BB, title I, § 102(d)(2), Dec. 27, 2020, 134 Stat. 2797.)

§ 18012. Rating reforms must apply uniformly to all health insurance issuers and group health plans

Any standard or requirement adopted by a State pursuant to this title,1

1 See References in Text note below.

or any amendment made by this title,1 shall be applied uniformly to all health plans in each insurance market to which the standard and requirements apply. The preceding sentence shall also apply to a State standard or requirement relating to the standard or requirement required by this title 1 (or any such amendment) that is not the same as the standard or requirement but that is not preempted under section 18041(d) of this title.

(Pub. L. 111–148, title I, § 1252, Mar. 23, 2010, 124 Stat. 162.)

§ 18013. Annual report on self-insured plans

Not later than 1 year after March 23, 2010, and annually thereafter, the Secretary of Labor shall prepare an aggregate annual report, using data collected from the Annual Return/Report of Employee Benefit Plan (Department of Labor Form 5500), that shall include general information on self-insured group health plans (including plan type, number of participants, benefits offered, funding arrangements, and benefit arrangements) as well as data from the financial filings of self-insured employers (including information on assets, liabilities, contributions, investments, and expenses). The Secretary shall submit such reports to the appropriate committees of Congress.

(Pub. L. 111–148, title I, § 1253, as added Pub. L. 111–148, title X, § 10103(f)(2), Mar. 23, 2010, 124 Stat. 895.)

§ 18014. Treatment of expatriate health plans under ACA

(a) In generalSubject to subsection (b), the provisions of (including any amendment made by) the Patient Protection and Affordable Care Act (Public Law 111–148) and of title I and subtitle B of title II of the Health Care and Education Reconciliation Act of 2010 (Public Law 111–152) shall not apply with respect to—

(1) expatriate health plans;

(2) employers with respect to such plans, solely in their capacity as plan sponsors for such plans; or

(3) expatriate health insurance issuers with respect to coverage offered by such issuers under such plans.

(b) Minimum essential coverage and reporting requirements

(1) In generalFor the purpose of section 5000A(f) of title 26, and any other section of title 26 that incorporates the definition of minimum essential coverage under such section 5000A(f) by reference:

(A) An expatriate health plan offered to primary enrollees who are described in subsections (d)(3)(A) and (d)(3)(B) of this section shall be treated as an eligible employer sponsored plan under 5000A(f)(2) of such title.

(B) An expatriate health plan offered to primary enrollees who are described in subsection (d)(3)(C) of this section shall be treated as a plan in the individual market under section 5000A(f)(1)(C) of such title. This subparagraph shall apply solely for the purposes of sections 36B, 5000A, and 6055 of such title.

(2) Exception

(1) In general

(2) Special ruleNotwithstanding paragraph (1), the fee under section 9010 1 of such Act for each of calendar years 2014 and 2015 with respect to any expatriate health insurance issuer shall be the amount which bears the same ratio to the fee amount determined by the Secretary of the Treasury with respect to such issuer under such section for each such year (determined without regard to this paragraph) as—

(A) the amount of premiums taken into account under such section with respect to such issuer for each such year, less the amount of premiums for expatriate health plans taken into account under such section with respect to such issuer for each such year, bears to

(B) the amount of premiums taken into account under such section with respect to such issuer for each such year.

(d) DefinitionsIn this section:

(1) Expatriate health insurance issuer

(2) Expatriate health planThe term “expatriate health plan” means a group health plan, health insurance coverage offered in connection with a group health plan, or health insurance coverage offered to a group of individuals described in paragraph (3)(C) (which may include spouses, dependents, and other individuals enrolled in the plan) that meets each of the following standards:

(A) Substantially all of the primary enrollees in such plan or coverage are qualified expatriates with respect to such plan or coverage. In applying the previous sentence, an individual shall not be considered a primary enrollee if the individual is not a national of the United States and the individual resides in the country of which the individual is a citizen.

(B) Substantially all of the benefits provided under the plan or coverage are not excepted benefits described in section 9832(c) of title 26.

(C) The plan or coverage provides coverage for inpatient hospital services, outpatient facility services, physician services, and emergency services (comparable to such emergency services coverage described in and offered under section 8903(1) of title 5 for plan year 2009)—

(i) in the case of individuals described in paragraph (3)(A), both in the United States and in the country or countries from which the individual was transferred or assigned (accounting for flexibility needed with existing coverage), and such other country or countries as the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, may designate (after taking into account the barriers and prohibitions to providing health care services in the countries as designated);

(ii) in the case of individuals described in paragraph (3)(B), in the country or countries in which the individual is present in connection with the individual’s employment, and such other country or countries as the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, may designate; or

(iii) in the case of individuals described in paragraph (3)(C), in the country or countries as the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, may designate.

(D) The plan sponsor reasonably believes that the benefits provided by the expatriate health plan satisfy a standard at least actuarially equivalent to the level provided for in section 36B(c)(2)(C)(ii) of title 26.

(E) If the plan or coverage provides dependent coverage of children, the plan or coverage makes such dependent coverage available for adult children until the adult child turns 26 years of age, unless such individual is the child of a child receiving dependent coverage.

(F) The plan or coverage—

(i) is issued by an expatriate health plan issuer, or administered by an administrator, that together with any other person in the expatriate health plan issuer’s or administrator’s controlled group (as described in section 9010 1 of the Patient Protection and Affordable Care Act (and the regulations promulgated thereunder)), has licenses to sell insurance in more than two countries, and, with respect to such plan, coverage, or company in the controlled group—(I) maintains network provider agreements that provide for direct claims payments, directly or through third party contracts, with health care providers in eight or more countries;(II) maintains call centers, directly or through third party contracts, in three or more countries and accepts calls from customers in eight or more languages;(III) processes (in the aggregate together with other plans or coverage it issues or administers) at least $1,000,000 in claims in foreign currency equivalents each year;(IV) makes available (directly or through third party contracts) global evacuation/repatriation coverage; and(V) maintains legal and compliance resources in three or more countries; and

(ii) offers reimbursements for items or services under such plan or coverage in the local currency in eight or more countries.

(G) The plan or coverage, and the plan sponsor or expatriate health insurance issuer with respect to such plan or coverage, satisfies the provisions of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.), chapter 100 of title 26, and part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et seq.), which would otherwise apply to such a plan or coverage, and sponsor or issuer, if not for the enactment of the Patient Protection and Affordable Care Act and title I and subtitle B of title II of the Health Care and Education Reconciliation Act of 2010.

(3) Qualified expatriateThe term “qualified expatriate” means a primary insured, or individual otherwise described in subparagraph (C)—

(A)

(i) whose skills, qualifications, job duties, or expertise is of a type that has caused his or her employer to transfer or assign him or her to the United States for a specific and temporary purpose or assignment tied to his or her employment; and

(ii) in connection with such transfer or assignment, is reasonably determined by the plan sponsor to require access to health insurance and other related services and support in multiple countries, and is offered other multinational benefits on a periodic basis (such as tax equalization, compensation for cross border moving expenses, or compensation to enable the expatriate to return to their home country);

(B) who is working outside of the United States for a period of at least 180 days in a consecutive 12-month period that overlaps with the plan year; or

(i) that is formed for the purpose of traveling or relocating internationally in service of one or more of the purposes listed in section 501(c)(3) or 501(c)(4) of title 26, or similarly situated organizations or groups (such as students or religious missionaries);

(ii) that is not formed primarily for the sale of health insurance coverage; and

(iii) that the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, determines requires access to health insurance and other related services and support in multiple countries.

(4) United States

(5) Miscellaneous terms

(A) Group health plan; health insurance coverage; health insurance issuer; plan sponsor

(B) Transfer

(e) Regulations

(f) Effective date

(Pub. L. 113–235, div. M, § 3, Dec. 16, 2014, 128 Stat. 2768.)