U.S Code last checked for updates: Jun 24, 2024
§ 18031.
Affordable choices of health benefit plans
(a)
Assistance to States to establish American Health Benefit Exchanges
(1)
Planning and establishment grants
(2)
Amount specified
(3)
Use of funds
(4)
Renewability of grant
(A)
In general
Subject to subsection (d)(4), the Secretary may renew a grant awarded under paragraph (1) if the State recipient of such grant—
(i)
is making progress, as determined by the Secretary, toward—
(I)
establishing an Exchange; and
(II)
implementing the reforms described in subtitles A and C (and the amendments made by such subtitles); and
(ii)
is meeting such other benchmarks as the Secretary may establish.
(B)
Limitation
(5)
Technical assistance to facilitate participation in SHOP Exchanges
(b)
American Health Benefit Exchanges
(1)
In general
Each State shall, not later than January 1, 2014, establish an American Health Benefit Exchange (referred to in this title 1
1
 See References in Text note below.
as an “Exchange”) for the State that—
(A)
facilitates the purchase of qualified health plans;
(B)
provides for the establishment of a Small Business Health Options Program (in this title 1 referred to as a “SHOP Exchange”) that is designed to assist qualified employers in the State who are small employers in facilitating the enrollment of their employees in qualified health plans offered in the small group market in the State; and
(C)
meets the requirements of subsection (d).
(2)
Merger of individual and SHOP Exchanges
(c)
Responsibilities of the Secretary
(1)
In general
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;
(D)
(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].
(2)
Rule of construction
(3)
Rating system
(4)
Enrollee satisfaction system
(5)
Internet portals
The Secretary shall—
(A)
continue to operate, maintain, and update the Internet portal developed under section 18003(a) of this title and to assist States in developing and maintaining their own such portal; and
(B)
make available for use by Exchanges a model template for an Internet portal that may be used to direct qualified individuals and qualified employers to qualified health plans, to assist such individuals and employers in determining whether they are eligible to participate in an Exchange or eligible for a premium tax credit or cost-sharing reduction, and to present standardized information (including quality ratings) regarding qualified health plans offered through an Exchange to assist consumers in making easy health insurance choices.
Such template shall include, with respect to each qualified health plan offered through the Exchange in each rating area, access to the uniform outline of coverage the plan is required to provide under section 2716 1 of the Public Health Service Act and to a copy of the plan’s written policy.
(6)
Enrollment periods
The Secretary shall require an Exchange to provide for—
(A)
an initial open enrollment, as determined by the Secretary (such determination to be made not later than July 1, 2012);
(B)
annual open enrollment periods, as determined by the Secretary for calendar years after the initial enrollment period;
(C)
special enrollment periods specified in section 9801 of title 26 and other special enrollment periods under circumstances similar to such periods under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.]; and
(D)
special monthly enrollment periods for Indians (as defined in section 1603 of title 25).
(7)
Reenrollment of certain individuals in qualified health plans in certain exchanges
(A)
In general
In the case of an Exchange that the Secretary operates pursuant to section 18041(c)(1) of this title, the Secretary shall establish a process under which an individual described in subparagraph (B) is reenrolled for plan year 2021 in a qualified health plan offered through such Exchange. Such qualified health plan under which such individual is so reenrolled shall be—
(i)
if available for plan year 2021, the qualified health plan under which such individual is enrolled during the annual open enrollment period for such plan year; and
(ii)
if such qualified health plan is not available for plan year 2021, a qualified health plan offered through such Exchange determined appropriate by the Secretary.
(B)
Individual described
An individual described in this subsection is an individual who, with respect to plan year 2020—
(i)
resides in a State with an Exchange described in subparagraph (A);
(ii)
is enrolled in a qualified health plan during such plan year and does not enroll in a qualified health plan for plan year 2021 during the annual open enrollment period for such plan year 2021; and
(iii)
does not elect to disenroll under a qualified health plan for plan year 2021 during such annual open enrollment period.
(d)
Requirements
(1)
In general
(2)
Offering of coverage
(A)
In general
(B)
Limitation
(i)
In general
(ii)
Offering of stand-alone dental benefits
(3)
Rules relating to additional required benefits
(A)
In general
(B)
States may require additional benefits
(i)
In general
(ii)
State must assume cost
A State shall make payments—
(I)
to an individual enrolled in a qualified health plan offered in such State; or
(II)
on behalf of an individual described in subclause (I) directly to the qualified health plan in which such individual is enrolled;
 to defray the cost of any additional benefits described in clause (i).
(4)
Functions
An Exchange shall, at a minimum—
(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;
(B)
provide for the operation of a toll-free telephone hotline to respond to requests for assistance;
(C)
maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans;
(D)
assign a rating to each qualified health plan offered through such Exchange in accordance with the criteria developed by the Secretary under subsection (c)(3);
(E)
utilize a standardized format for presenting health benefits plan options in the Exchange, including the use of the uniform outline of coverage established under section 2715 of the Public Health Service Act [42 U.S.C. 300gg–15];
(F)
in accordance with section 18083 of this title, inform individuals of eligibility requirements for the medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], the CHIP program under title XXI of such Act [42 U.S.C. 1397aa et seq.], or any applicable State or local public program and if through screening of the application by the Exchange, the Exchange determines that such individuals are eligible for any such program, enroll such individuals in such program;
(G)
establish and make available by electronic means a calculator to determine the actual cost of coverage after the application of any premium tax credit under section 36B of title 26 and any cost-sharing reduction under section 18071 of this title;
(H)
subject to section 18081 of this title, grant a certification attesting that, for purposes of the individual responsibility penalty under section 5000A of title 26, an individual is exempt from the individual requirement or from the penalty imposed by such section because—
(i)
there is no affordable qualified health plan available through the Exchange, or the individual’s employer, covering the individual; or
(ii)
the individual meets the requirements for any other such exemption from the individual responsibility requirement or penalty;
(I)
transfer to the Secretary of the Treasury—
(i)
a list of the individuals who are issued a certification under subparagraph (H), including the name and taxpayer identification number of each individual;
(ii)
the name and taxpayer identification number of each individual who was an employee of an employer but who was determined to be eligible for the premium tax credit under section 36B of title 26 because—
(I)
the employer did not provide minimum essential coverage; or
(II)
the employer provided such minimum essential coverage but it was determined under section 36B(c)(2)(C) of such title to either be unaffordable to the employee or not provide the required minimum actuarial value; and
(iii)
the name and taxpayer identification number of each individual who notifies the Exchange under section 18081(b)(4) of this title that they have changed employers and of each individual who ceases coverage under a qualified health plan during a plan year (and the effective date of such cessation);
(J)
provide to each employer the name of each employee of the employer described in subparagraph (I)(ii) who ceases coverage under a qualified health plan during a plan year (and the effective date of such cessation); and
(K)
establish the Navigator program described in subsection (i).
(5)
Funding limitations
(A)
No Federal funds for continued operations
(B)
Prohibiting wasteful use of funds
(6)
Consultation
An Exchange shall consult with stakeholders relevant to carrying out the activities under this section, including—
(A)
educated health care consumers who are enrollees in qualified health plans;
(B)
individuals and entities with experience in facilitating enrollment in qualified health plans;
(C)
representatives of small businesses and self-employed individuals;
(D)
State Medicaid offices; and
(E)
advocates for enrolling hard to reach populations.
(7)
Publication of costs
(e)
Certification
(1)
In general
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.
(2)
Premium considerations
(3)
Transparency in coverage
(A)
In general
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.
(B)
Use of plain language
(C)
Cost sharing transparency
(D)
Group health plans
(f)
Flexibility
(1)
Regional or other interstate exchanges
An Exchange may operate in more than one State if—
(A)
each State in which such Exchange operates permits such operation; and
(B)
the Secretary approves such regional or interstate Exchange.
(2)
Subsidiary Exchanges
A State may establish one or more subsidiary Exchanges if—
(A)
each such Exchange serves a geographically distinct area; and
(B)
the area served by each such Exchange is at least as large as a rating area described in section 2701(a) of the Public Health Service Act [42 U.S.C. 300gg(a)].
(3)
Authority to contract
(A)
In general
(B)
Eligible entity
In this paragraph, the term “eligible entity” means—
(i)
a person—
(I)
incorporated under, and subject to the laws of, 1 or more States;
(II)
that has demonstrated experience on a State or regional basis in the individual and small group health insurance markets and in benefits coverage; and
(III)
that is not a health insurance issuer or that is treated under subsection (a) or (b) of section 52 of title 26 as a member of the same controlled group of corporations (or under common control with) as a health insurance issuer; or
(ii)
the State medicaid agency under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.].
(g)
Rewarding quality through market-based incentives
(1)
Strategy described
A strategy described in this paragraph is a payment structure that provides increased reimbursement or other incentives for—
(A)
improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model, for treatment or services under the plan or coverage;
(B)
the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;
(C)
the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage;
(D)
the implementation of wellness and health promotion activities; and
(E)
the implementation of activities to reduce health and health care disparities, including through the use of language services, community outreach, and cultural competency trainings.
(2)
Guidelines
(3)
Requirements
(h)
Quality improvement
(1)
Enhancing patient safety
Beginning on January 1, 2015, a qualified health plan may contract with—
(A)
a hospital with greater than 50 beds only if such hospital—
(i)
utilizes a patient safety evaluation system as described in part C of title IX of the Public Health Service Act [42 U.S.C. 299b–21 et seq.]; and
(ii)
implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; or
(B)
a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.
(2)
Exceptions
(3)
Adjustment
(i)
Navigators
(1)
In general
(2)
Eligibility
(A)
In general
(B)
Types
Entities described in subparagraph (A) may include trade, industry, and professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, resource partners of the Small Business Administration, other licensed insurance agents and brokers, and other entities that—
(i)
are capable of carrying out the duties described in paragraph (3);
(ii)
meet the standards described in paragraph (4); and
(iii)
provide information consistent with the standards developed under paragraph (5).
(3)
Duties
An entity that serves as a navigator under a grant under this subsection shall—
(A)
conduct public education activities to raise awareness of the availability of qualified health plans;
(B)
distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under section 36B of title 26 and cost-sharing reductions under section 18071 of this title;
(C)
facilitate enrollment in qualified health plans;
(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
(E)
provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges.
(4)
Standards
(A)
In general
The Secretary shall establish standards for navigators under this subsection, including provisions to ensure that any private or public entity that is selected as a navigator is qualified, and licensed if appropriate, to engage in the navigator activities described in this subsection and to avoid conflicts of interest. Under such standards, a navigator shall not—
(i)
be a health insurance issuer; or
(ii)
receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or employees of a qualified employer in a qualified health plan.
(5)
Fair and impartial information and services
(6)
Funding
(j)
Applicability of mental health parity
(k)
Conflict
(Pub. L. 111–148, title I, § 1311, title X, §§ 10104(e)–(h), 10203(a), Mar. 23, 2010, 124 Stat. 173, 900, 901, 927; Pub. L. 116–94, div. N, title I, § 608, Dec. 20, 2019, 133 Stat. 3130.)
cite as: 42 USC 18031