42 USC 18054 - Multi-State plans

U.S Code last checked for updates: May 02, 2024

§ 18054.

Multi-State plans

(a)

Oversight by the Office of Personnel Management

(1)

In general

(2)

Terms

(3)

Non-profit entities

(4)

Administration

The Director shall implement this subsection in a manner similar to the manner in which the Director implements the contracting provisions with respect to carriers under the Federal employees health benefit program 1

 So in original. The words “employees health benefit program” probably should be capitalized.

under chapter 89 of title 5, including (through negotiating with each multi-state 2

 So in original. Probably should be “multi-State”.

plan)—

(A)

a medical loss ratio;

(B)

a profit margin;

(C)

the premiums to be charged; and

(D)

such other terms and conditions of coverage as are in the interests of enrollees in such plans.

(5)

Authority to protect consumers

(6)

Assured availability of varied coverage

(7)

Withdrawal

(b)

Eligibility

A health insurance issuer shall be eligible to enter into a contract under subsection (a)(1) if such issuer—

(1)

agrees to offer a multi-State qualified health plan that meets the requirements of subsection (c) in each Exchange in each State;

(2)

is licensed in each State and is subject to all requirements of State law not inconsistent with this section, including the standards and requirements that a State imposes that do not prevent the application of a requirement of part A of title XXVII of the Public Health Service Act [42 U.S.C. 300gg et seq.] or a requirement of this title; 3

 See References in Text note below.

(3)

otherwise complies with the minimum standards prescribed for carriers offering health benefits plans under section 8902(e) of title 5 to the extent that such standards do not conflict with a provision of this title; ³ and

(4)

meets such other requirements as determined appropriate by the Director, in consultation with the Secretary.

(c)

Requirements for multi-State qualified health plan

(1)

In general

A multi-State qualified health plan meets the requirements of this subsection if, in the determination of the Director—

(A)

the plan offers a benefits package that is uniform in each State and consists of the essential benefits described in section 18022 of this title;

(B)

the plan meets all requirements of this title ³ with respect to a qualified health plan, including requirements relating to the offering of the bronze, silver, and gold levels of coverage and catastrophic coverage in each State Exchange;

(C)

except as provided in paragraph (5), the issuer provides for determinations of premiums for coverage under the plan on the basis of the rating requirements of part A of title XXVII of the Public Health Service Act; and

(D)

the issuer offers the plan in all geographic regions, and in all States that have adopted adjusted community rating before March 23, 2010.

(2)

States may offer additional benefits

(3)

Credits

(A)

In general

(B)

No additional Federal cost

(4)

State must assume cost

A State shall make payments—

(A)

to an individual enrolled in a multi-State qualified health plan offered in such State; or

(B)

on behalf of an individual described in subparagraph (A) directly to the multi-State qualified health plan in which such individual is enrolled;

to defray the cost of any additional benefits described in paragraph (2).

(5)

Application of certain State rating requirements

(d)

Plans deemed to be certified

(e)

Phase-in

Notwithstanding paragraphs (1) and (2) of subsection (b), the Director shall enter into a contract with a health insurance issuer for the offering of a multi-State qualified health plan under subsection (a) if—

(1)

with respect to the first year for which the issuer offers such plan, such issuer offers the plan in at least 60 percent of the States;

(2)

with respect to the second such year, such issuer offers the plan in at least 70 percent of the States;

(3)

with respect to the third such year, such issuer offers the plan in at least 85 percent of the States; and

(4)

with respect to each subsequent year, such issuer offers the plan in all States.

(f)

Applicability

(g)

Continued support for FEHBP

(1)

Maintenance of effort

(2)

Separate risk pool

(3)

Authority to establish separate entities

(4)

Effective oversight

(5)

Assurance of separate program

(6)

FEHBP plans not required to participate

(h)

Advisory board

(i)

Authorization of appropriations

(Pub. L. 111–148, title I, § 1334, as added Pub. L. 111–148, title X, § 10104(q), Mar. 23, 2010, 124 Stat. 902.)

cite as: 42 USC 18054