US Codex
U.S.C.
Notes

§18021. Qualified health plan defined — Inbound Citations

42 U.S.C. § 18021

Cited by 311 provisions in release 119-102.

Citations to §18021(a)

Citations to §18021(a)(1)

Citations to §18021(b)(1)(A)

  • 42 U.S.C. § 18001(e)(1)
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    (1) The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual’s health status.
  • 42 U.S.C. § 18001(e)(2)
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    (2) An issuer or employment-based health plan shall be responsible for reimbursing the program under this section for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in coverage through the program. The criteria shall include at least the following circumstances:
    (A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage.
    (B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan—
    (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or
    (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)—
    (I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or
    (II) the prior coverage is a policy for which duration of coverage form1 issue or health status are factors that can be considered in determining premiums at renewal.
  • 42 U.S.C. § 18001(e)(2)(B)
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    (B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan—
    (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or
    (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)—
    (I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or
    (II) the prior coverage is a policy for which duration of coverage form1 issue or health status are factors that can be considered in determining premiums at renewal.
  • 42 U.S.C. § 18011(a)(3)
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    (3) The provisions of sections 2715 [42 U.S.C. 300gg–15] and 2718 [42 U.S.C. 300gg–18] of the Public Health Service Act (as added by subtitle A) shall apply to grandfathered health plans for plan years beginning on or after March 23, 2010.
  • 42 U.S.C. § 18011(a)(4)(A)
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    (A) The following provisions of the Public Health Service Act [42 U.S.C. 201 et seq.] (as added by this title)1 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).
  • 42 U.S.C. § 18011(a)(4)(B)(i)
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    (i) Those provisions of section 2711 [42 U.S.C. 300gg–11] relating to annual limits and the provisions of section 2704 [42 U.S.C. 300gg–3] (relating to pre-existing condition exclusions) of the Public Health Service Act (as added by this subtitle) shall apply to grandfathered health plans that are group health plans for plan years beginning with the first plan year to which such provisions otherwise apply.
  • 42 U.S.C. § 18011(a)(4)(B)(ii)
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    (ii) For plan years beginning before January 1, 2014, the provisions of section 2714 of the Public Health Service Act [42 U.S.C. 300gg–14] (as added by this subtitle) shall apply in the case of an adult child with respect to a grandfathered health plan that is a group health plan only if such adult child is not eligible to enroll in an eligible employer-sponsored health plan (as defined in section 5000A(f)(2) of title 26) other than such grandfathered health plan.
  • 42 U.S.C. § 18011(a)(5)
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    (5) Sections 300gg–111, 300gg–112, and 300gg–117 of this title shall apply to grandfathered health plans for plan years beginning on or after January 1, 2022.
  • 42 U.S.C. § 18011(e)
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    (e) In this title,1 the term “grandfathered health plan” means any group health plan or health insurance coverage to which this section applies.
  • 42 U.S.C. § 18012
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    Any standard or requirement adopted by a State pursuant to this title,1 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 title1 (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.
  • 42 U.S.C. § 18014(a)(1)
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    (1) expatriate health plans;
  • 42 U.S.C. § 18014(b)(1)(A)
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    (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.
  • 42 U.S.C. § 18014(b)(1)(B)
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    (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.
  • 42 U.S.C. § 18014(c)(1)
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    (1) For purposes of section 90101 of the Patient Protection and Affordable Care Act (26 U.S.C. 4001) note prec.), for calendar years after 2015, a qualified expatriate (and any spouse, dependent, or any other individual enrolled in the plan) enrolled in an expatriate health plan shall not be considered a United States health risk.
  • 42 U.S.C. § 18014(c)(2)(A)
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    (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
  • 42 U.S.C. § 18014(d)(1)
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    (1) The term “expatriate health insurance issuer” means a health insurance issuer that issues expatriate health plans.
  • 42 U.S.C. § 18014(d)(2)
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    (2) The 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 90101 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.
  • 42 U.S.C. § 18014(d)(2)(D)
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    (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.
  • 42 U.S.C. § 18014(d)(2)(F)(i)
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    (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 90101 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
  • 42 U.S.C. § 18014(f)
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    (f) Unless otherwise specified, this Act shall take effect on December 16, 2014, and shall apply only to expatriate health plans issued or renewed on or after July 1, 2015.
  • 42 U.S.C. § 18022(a)
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    (a) In this title,1 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 platinum level of coverage described in subsection (d).
  • 42 U.S.C. § 18022(b)(4)(F)
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    (F) provide that if a plan described in section 18031(b)(2)(B)(ii)3 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); and4
  • 42 U.S.C. § 18022(b)(5)
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    (5) Nothing in this title1 shall be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this subsection.
  • 42 U.S.C. § 18022(c)(1)(A)
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    (A) The cost-sharing incurred under a health plan with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223(c)(2)(A)(ii) of title 26 for self-only and family coverage, respectively, for taxable years beginning in 2014.
  • 42 U.S.C. § 18022(e)(1)
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    (1) A health plan not providing a bronze, silver, gold, or platinum 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.
  • 42 U.S.C. § 18022(e)(3)
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    (3) If a health insurance issuer offers a health plan described in this subsection, the issuer may only offer the plan in the individual market.
  • 42 U.S.C. § 18023(b)(2)(E)(i)
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    (i) Subject to clause (ii), State health insurance commissioners shall ensure that health plans comply with the segregation requirements in this subsection through the segregation of plan funds in accordance with applicable provisions of generally accepted accounting requirements, circulars on funds management of the Office of Management and Budget, and guidance on accounting of the Government Accountability Office.
  • 42 U.S.C. § 18023(b)(2)(E)(ii)
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    (ii) Nothing in clause (i) shall prohibit the right of an individual or health plan to appeal such action in courts of competent jurisdiction.
  • 42 U.S.C. § 18031(c)(1)
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    (1) The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified health plans. Such criteria shall require that, to be certified, a plan shall, at a minimum—
    (A) meet marketing requirements, and not employ marketing practices or benefit designs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs;
    (B) ensure a sufficient choice of providers (in a manner consistent with applicable network adequacy provisions under section 2702(c) of the Public Health Service Act [42 U.S.C. 300gg–1(c)]), and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers;
    (C) include within health insurance plan networks those essential community providers, where available, that serve predominately low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act [42 U.S.C. 256b(a)(4)] and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act [42 U.S.C. 1396r–8(c)(1)(D)(i)(IV)] as set forth by section 221 of Public Law 111–8, except that nothing in this subparagraph shall be construed to require any health plan to provide coverage for any specific medical procedure;
    (i) be accredited with respect to local performance on clinical quality measures such as the Healthcare Effectiveness Data and Information Set, patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey, as well as consumer access, utilization management, quality assurance, provider credentialing, complaints and appeals, network adequacy and access, and patient information programs by any entity recognized by the Secretary for the accreditation of health insurance issuers or plans (so long as any such entity has transparent and rigorous methodological and scoring criteria); or
    (ii) receive such accreditation within a period established by an Exchange for such accreditation that is applicable to all qualified health plans;
    (E) implement a quality improvement strategy described in subsection (g)(1);
    (F) utilize a uniform enrollment form that qualified individuals and qualified employers may use (either electronically or on paper) in enrolling in qualified health plans offered through such Exchange, and that takes into account criteria that the National Association of Insurance Commissioners develops and submits to the Secretary;
    (G) utilize the standard format established for presenting health benefits plan options;
    (H) provide information to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, on any quality measures for health plan performance endorsed under section 399JJ of the Public Health Service Act [42 U.S.C. 280j–2], as applicable; and
    (I) report to the Secretary at least annually and in such manner as the Secretary shall require, pediatric quality reporting measures consistent with the pediatric quality reporting measures established under section 1139A of the Social Security Act [42 U.S.C. 1320b–9a].
  • 42 U.S.C. § 18031(c)(1)(C)
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    (C) include within health insurance plan networks those essential community providers, where available, that serve predominately low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act [42 U.S.C. 256b(a)(4)] and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act [42 U.S.C. 1396r–8(c)(1)(D)(i)(IV)] as set forth by section 221 of Public Law 111–8, except that nothing in this subparagraph shall be construed to require any health plan to provide coverage for any specific medical procedure;
  • 42 U.S.C. § 18031(c)(1)(H)
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    (H) provide information to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, on any quality measures for health plan performance endorsed under section 399JJ of the Public Health Service Act [42 U.S.C. 280j–2], as applicable; and
  • 42 U.S.C. § 18031(d)(2)(B)(i)
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    (i) An Exchange may not make available any health plan that is not a qualified health plan.
  • 42 U.S.C. § 18031(d)(4)(A)
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    (A) implement procedures for the certification, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (c), of health plans as qualified health plans;
  • 42 U.S.C. § 18031(e)(1)
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    (1) An Exchange may certify a health plan as a qualified health plan if—
    (A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection (c)(1); and
    (B) the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State or States in which such Exchange operates, except that the Exchange may not exclude a health plan—
    (i) on the basis that such plan is a fee-for-service plan;
    (ii) through the imposition of premium price controls; or
    (iii) on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Exchange determines are inappropriate or too costly.
  • 42 U.S.C. § 18031(e)(1)(A)
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    (A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection (c)(1); and
  • 42 U.S.C. § 18031(e)(1)(B)
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    (B) the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State or States in which such Exchange operates, except that the Exchange may not exclude a health plan—
    (i) on the basis that such plan is a fee-for-service plan;
    (ii) through the imposition of premium price controls; or
    (iii) on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Exchange determines are inappropriate or too costly.
  • 42 U.S.C. § 18031(e)(2)
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    (2) The Exchange shall require health plans seeking certification as qualified health plans to submit a justification for any premium increase prior to implementation of the increase. Such plans shall prominently post such information on their websites. The Exchange shall take this information, and the information and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public Health Service Act [42 U.S.C. 300gg–94(b)(1)] (relating to patterns or practices of excessive or unjustified premium increases), into consideration when determining whether to make such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States.
  • 42 U.S.C. § 18031(e)(3)(A)
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    (A) The Exchange shall require health plans seeking certification as qualified health plans to submit to the Exchange, the Secretary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of the following information:
    (i) Claims payment policies and practices.
    (ii) Periodic financial disclosures.
    (iii) Data on enrollment.
    (iv) Data on disenrollment.
    (v) Data on the number of claims that are denied.
    (vi) Data on rating practices.
    (vii) Information on cost-sharing and payments with respect to any out-of-network coverage.
    (viii) Information on enrollee and participant rights under this title.1
    (ix) Other information as determined appropriate by the Secretary.
  • 42 U.S.C. § 18031(e)(3)(C)
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    (C) The Exchange shall require health plans seeking certification as qualified health plans to permit individuals to learn the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider in a timely manner upon the request of the individual. At a minimum, such information shall be made available to such individual through an Internet website and such other means for individuals without access to the Internet.
  • 42 U.S.C. § 18031(i)(3)(D)
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    (D) provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Service Act [42 U.S.C. 300gg–93], or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and
  • 42 U.S.C. § 18032(c)(1)
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    (1) A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the individual market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.
  • 42 U.S.C. § 18032(c)(2)
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    (2) A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the small group market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.
  • 42 U.S.C. § 18032(c)(4)
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    (4) A State law requiring grandfathered health plans to be included in a pool described in paragraph (1) or (2) shall not apply.
  • 42 U.S.C. § 18032(d)(1)(A)
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    (A) a health insurance issuer from offering outside of an Exchange a health plan to a qualified individual or qualified employer; and
  • 42 U.S.C. § 18032(d)(1)(B)
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    (B) a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health plan offered outside of an Exchange.
  • 42 U.S.C. § 18032(d)(3)(D)(i)
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    (i) Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are—
    (I) created under this Act (or an amendment made by this Act); or
    (II) offered through an Exchange established under this Act (or an amendment made by this Act).
  • 42 U.S.C. § 18042(c)(6)
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    (6) An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization does not offer a health plan in a State until that State has in effect (or the Secretary has implemented for the State) the market reforms required by part A of title XXVII of the Public Health Service Act [42 U.S.C. 300gg et seq.] (as amended by subtitles A and C of this Act).
  • 42 U.S.C. § 18051(a)(1)
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    (1) The Secretary shall establish a basic health program meeting the requirements of this section under which a State may enter into contracts to offer 1 or more standard health plans providing at least the essential health benefits described in section 18022(b) of this title to eligible individuals in lieu of offering such individuals coverage through an Exchange.
  • 42 U.S.C. § 18051(a)(2)
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    (2) Such program shall provide that a State may not establish a basic health program under this section unless the State establishes to the satisfaction of the Secretary, and the Secretary certifies, that—
    (A) in the case of an eligible individual enrolled in a standard health plan offered through the program, the State provides—
    (i) that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individual’s dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay (in the rating area in which the individual resides) if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of title 26) offered to the individual through an Exchange; and
    (ii) that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed—
    (I) the cost-sharing required under a platinum plan in the case of an eligible individual with household income not in excess of 150 percent of the poverty line for the size of the family involved; and
    (II) the cost-sharing required under a gold plan in the case of an eligible individual not described in subclause (I); and
    (B) the benefits provided under the standard health plans offered through the program cover at least the essential health benefits described in section 18022(b) of this title.
    For purposes of subparagraph (A)(i), the amount of the monthly premium an individual is required to pay under either the standard health plan or the applicable second lowest cost silver plan shall be determined after reduction for any premium tax credits and cost-sharing reductions allowable with respect to either plan.
  • 42 U.S.C. § 18051(a)(2)(A)
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    (A) in the case of an eligible individual enrolled in a standard health plan offered through the program, the State provides—
    (i) that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individual’s dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay (in the rating area in which the individual resides) if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of title 26) offered to the individual through an Exchange; and
    (ii) that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed—
    (I) the cost-sharing required under a platinum plan in the case of an eligible individual with household income not in excess of 150 percent of the poverty line for the size of the family involved; and
    (II) the cost-sharing required under a gold plan in the case of an eligible individual not described in subclause (I); and
  • 42 U.S.C. § 18051(a)(2)(A)(i)
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    (i) that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individual’s dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay (in the rating area in which the individual resides) if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of title 26) offered to the individual through an Exchange; and
  • 42 U.S.C. § 18051(a)(2)(A)(ii)
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    (ii) that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed—
    (I) the cost-sharing required under a platinum plan in the case of an eligible individual with household income not in excess of 150 percent of the poverty line for the size of the family involved; and
    (II) the cost-sharing required under a gold plan in the case of an eligible individual not described in subclause (I); and
  • 42 U.S.C. § 18051(a)(2)(B)
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    (B) the benefits provided under the standard health plans offered through the program cover at least the essential health benefits described in section 18022(b) of this title.
  • 42 U.S.C. § 18051(c)(1)
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    (1) A State basic health program shall establish a competitive process for entering into contracts with standard health plans under subsection (a), including negotiation of premiums and cost-sharing and negotiation of benefits in addition to the essential health benefits described in section 18022(b) of this title.
  • 42 U.S.C. § 18051(c)(2)(A)
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    (A) Negotiation with offerors of a standard health plan for the inclusion of innovative features in the plan, including—
    (i) care coordination and care management for enrollees, especially for those with chronic health conditions;
    (ii) incentives for use of preventive services; and
    (iii) the establishment of relationships between providers and patients that maximize patient involvement in health care decision-making, including providing incentives for appropriate utilization under the plan.
  • 42 U.S.C. § 18051(c)(2)(D)
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    (D) Establishing specific performance measures and standards for issuers of standard health plans that focus on quality of care and improved health outcomes, requiring such plans to report to the State with respect to the measures and standards, and making the performance and quality information available to enrollees in a useful form.
  • 42 U.S.C. § 18051(c)(3)(A)
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    (A) A State shall, to the maximum extent feasible, seek to make multiple standard health plans available to eligible individuals within a State to ensure individuals have a choice of such plans.
  • 42 U.S.C. § 18051(c)(3)(B)
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    (B) A State may negotiate a regional compact with other States to include coverage of eligible individuals in all such States in agreements with issuers of standard health plans.
  • 42 U.S.C. § 18051(c)(4)
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    (4) A State shall seek to coordinate the administration of, and provision of benefits under, its program under this section with the State medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], the State child health plan under title XXI of such Act [42 U.S.C. 1397aa et seq.], and other State-administered health programs to maximize the efficiency of such programs and to improve the continuity of care.
  • 42 U.S.C. § 18051(d)(1)
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    (1) If the Secretary determines that a State electing the application of this section meets the requirements of the program established under subsection (a), the Secretary shall transfer to the State for each fiscal year for which 1 or more standard health plans are operating within the State the amount determined under paragraph (3).
  • 42 U.S.C. § 18051(d)(2)
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    (2) A State shall establish a trust for the deposit of the amounts received under paragraph (1) and amounts in the trust fund shall only be used to reduce the premiums and cost-sharing of, or to provide additional benefits for, eligible individuals enrolled in standard health plans within the State. Amounts in the trust fund, and expenditures of such amounts, shall not be included in determining the amount of any non-Federal funds for purposes of meeting any matching or expenditure requirement of any federally-funded program.
  • 42 U.S.C. § 18051(d)(3)(A)(i)
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    (i) The amount determined under this paragraph for any fiscal year is the amount the Secretary determines is equal to 95 percent of the premium tax credits under section 36B of title 26, and the cost-sharing reductions under section 18071 of this title, that would have been provided for the fiscal year to eligible individuals enrolled in standard health plans in the State if such eligible individuals were allowed to enroll in qualified health plans through an Exchange established under this subchapter.
  • 42 U.S.C. § 18051(d)(4)
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    (4) The provisions of section 18023 of this title shall apply to a State basic health program, and to standard health plans offered through such program, in the same manner as such rules apply to qualified health plans.
  • 42 U.S.C. § 18051(g)
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    (g) A State may provide that persons eligible to offer standard health plans under a basic health program established under this section may include a licensed health maintenance organization, a licensed health insurance insurer, or a network of health care providers established to offer services under the program.
  • 42 U.S.C. § 18054(a)(5)
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    (5) The Director may prohibit the offering of any multi-State health plan that does not meet the terms and conditions defined by the Director with respect to the elements described in subparagraphs (A) through (D) of paragraph (4).
  • 42 U.S.C. § 18061(b)(1)(B)
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    (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.
  • 42 U.S.C. § 18063(a)(1)
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    (1) Using the criteria and methods developed under subsection (b), each State shall assess a charge on health plans and health insurance issuers (with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all plans or coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1001 et seq.]).
  • 42 U.S.C. § 18063(a)(2)
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    (2) Using the criteria and methods developed under subsection (b), each State shall provide a payment to health plans and health insurance issuers (with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).
  • 42 U.S.C. § 18063(c)
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    (c) A health plan or a health insurance issuer is described in this subsection if such health plan or health insurance issuer provides coverage in the individual or small group market within the State. This subsection shall not apply to a grandfathered health plan or the issuer of a grandfathered health plan with respect to that plan.
  • 42 U.S.C. § 18083(e)(4)
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    (4) a State program under section 18051 of this title establishing qualified basic health plans.
  • 42 U.S.C. § 18113(a)
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    (a) The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), may not subject an individual or institutional health care entity to discrimination on the basis that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.

Citations to §18021(b)(2)

Citations to §18021(b)(3)