42 USC 18051 - State flexibility to establish basic health programs for low-income individuals not eligible for medicaid

U.S Code last checked for updates: May 05, 2024

§ 18051.

State flexibility to establish basic health programs for low-income individuals not eligible for medicaid

(a)

Establishment of program

(1)

In general

(2)

Certifications as to benefit coverage and costs

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.

(b)

Standard health plan

In this section, the term “standard heath 1

 So in original. Probably should be “health”.

plan” means a health benefits plan that the State contracts with under this section—

(1)

under which the only individuals eligible to enroll are eligible individuals;

(2)

that provides at least the essential health benefits described in section 18022(b) of this title; and

(3)

in the case of a plan that provides health insurance coverage offered by a health insurance issuer, that has a medical loss ratio of at least 85 percent.

(c)

Contracting process

(1)

In general

(2)

Specific items to be considered

A State shall, as part of its competitive process under paragraph (1), include at least the following:

(A)

Innovation

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.

(B)

Health and resource differences

(C)

Managed care

(D)

Performance measures

(3)

Enhanced availability

(A)

Multiple plans

(B)

Regional compacts

(4)

Coordination with other State programs

(d)

Transfer of funds to States

(1)

In general

(2)

Use of funds

(3)

Amount of payment

(A)

Secretarial determination

(i)

In general

(ii)

Specific requirements

(iii)

Certification

(B)

Corrections

(4)

Application of special rules

(e)

Eligible individual

(1)

In general

In this section, the term “eligible individual” means, with respect to any State, an individual—

(A)

who a 2

 So in original. Probably should be preceded by “is”.

resident of the State who is not eligible to enroll in the State’s medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] for benefits that at a minimum consist of the essential health benefits described in section 18022(b) of this title;

(B)

whose household income exceeds 133 percent but does not exceed 200 percent of the poverty line for the size of the family involved, or, in the case of an alien lawfully present in the United States, whose income is not greater than 133 percent of the poverty line for the size of the family involved but who is not eligible for the Medicaid program under title XIX of the Social Security Act by reason of such alien status;

(C)

who is not eligible for minimum essential coverage (as defined in section 5000A(f) of title 26) or is eligible for an employer-sponsored plan that is not affordable coverage (as determined under section 5000A(e)(2) of such title); and

(D)

who has not attained age 65 as of the beginning of the plan year.

Such term shall not include any individual who is not a qualified individual under section 18032 of this title who is eligible to be covered by a qualified health plan offered through an Exchange.

(2)

Eligible individuals may not use Exchange

(f)

Secretarial oversight

The Secretary shall each year conduct a review of each State program to ensure compliance with the requirements of this section, including ensuring that the State program meets—

(1)

eligibility verification requirements for participation in the program;

(2)

the requirements for use of Federal funds received by the program; and

(3)

the quality and performance standards under this section.

(g)

Standard health plan offerors

(h)

Definitions

(Pub. L. 111–148, title I, § 1331, title X, § 10104(o), Mar. 23, 2010, 124 Stat. 199, 902.)

cite as: 42 USC 18051