42 U.S.C. § 18021 — Qualified health plan defined

submitted 16 years ago by Pub. L. 111-148 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 509 words · no verdicts yet

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A "qualified health plan" is a health plan certified by an Exchange, that covers the essential health benefits package, and that's sold by a properly licensed insurer who offers at least one silver and one gold plan and charges the same price whether sold on or off the Exchange. This includes CO-OP and multi-state plans, and premiums can vary by geographic rating area.

(a) What counts as a qualified health plan (1) A "qualified health plan" is a health plan that: (A) has a certification — from every Exchange that offers it — showing it meets the criteria in section 18031(c); (B) covers the "essential health benefits package" described in section 18022(a); and (C) is sold by a health insurance issuer that (i) is properly licensed in every state where it sells coverage, (ii) agrees to offer at least one silver-level and one gold-level plan through each Exchange it participates in, (iii) agrees to charge the same premium for a plan no matter whether it's bought through the Exchange, directly, or through an agent, and (iv) follows the Secretary's regulations under section 18031(d) and any other rules the Exchange sets. (2) Wherever this title refers to a "qualified health plan," that includes CO-OP plans offered under section 18042 and multi-state plans offered under section 18054, unless stated otherwise. (3) The Secretary may let a qualified health plan deliver its coverage through a "direct primary care medical home plan" that meets standards the Secretary sets, as long as the qualified health plan still meets every other requirement and coordinates care with the medical home plan. (4) A qualified health plan — including a multi-state one — may charge different premiums in different geographic rating areas, as defined in section 300gg(a)(2). (b) Related definitions (1) "Health plan" means health insurance coverage and a group health plan. It does not include a self-insured group health plan or a multiple employer welfare arrangement (MEWA) that isn't subject to state insurance regulation under 29 U.S.C. § 1144. (2) "Health insurance coverage" and "health insurance issuer" mean what section 300gg–91(b) says they mean. (3) "Group health plan" means what section 300gg–91(a) says it means.

the actual law source: uscode.house.gov ↗public domain

(a) Qualified health plan

In this title: 1

(1) In general

The term “qualified health plan” means a health plan that—

(A)

has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 18031(c) of this title issued or recognized by each Exchange through which such plan is offered;

(B)

provides the essential health benefits package described in section 18022(a) of this title; and

(C)

is offered by a health insurance issuer that—

(i)

is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title; ¹

(ii)

agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange;

(iii)

agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and

(iv)

complies with the regulations developed by the Secretary under section 18031(d) of this title and such other requirements as an applicable Exchange may establish.

(2) Inclusion of CO–OP plans and multi-State qualified health plans

Any reference in this title ¹ to a qualified health plan shall be deemed to include a qualified health plan offered through the CO–OP program under section 18042 of this title, and a multi-State plan under section 18054 of this title, unless specifically provided for otherwise.

(3) Treatment of qualified direct primary care medical home plans

The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.

(4) Variation based on rating area

A qualified health plan, including a multi-State qualified health plan, may as appropriate vary premiums by rating area (as defined in section 300gg(a)(2) of this title).

(b) Terms relating to health plans

In this title: ¹

(1) Health plan

(A) In general

The term “health plan” means health insurance coverage and a group health plan.

(B) Exception for self-insured plans and MEWAs

Except to the extent specifically provided by this title,¹ the term “health plan” shall not include a group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to State insurance regulation under section 1144 of title 29.

(2) Health insurance coverage and issuer

The terms “health insurance coverage” and “health insurance issuer” have the meanings given such terms by section 300gg–91(b) of this title.

(3) Group health plan

The term “group health plan” has the meaning given such term by section 300gg–91(a) of this title.

Source credit: (Pub. L. 111–148, title I, § 1301, title X, § 10104(a), Mar. 23, 2010, 124 Stat. 162, 896.)

history & why it existsrecord from the source credit

2010Enacted · Pub. L. 111-148 · 124 Stat. 162, 896

A history note hasn’t been published yet. The record shows enactment by Pub. L. 111-148 on 2010-03-23.

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