42 U.S.C. § 18071 — Reduced cost-sharing for individuals enrolling in qualified health plans

(a) In general If someone is an "eligible insured" enrolled in a qualified health plan, the Secretary tells the plan's issuer, and the issuer must lower that person's cost-sharing (deductibles, copays, and similar charges) by the amount set out in subsection (c). (b) Eligible insured An "eligible insured" is someone who (1) enrolls in a silver-level qualified health plan in the individual market through an Exchange, and (2) has household income between 100 percent and 400 percent of the poverty line for their family size. Someone described in section 36B(c)(1)(B) of title 26 is treated as having income at exactly 100 percent for purposes of this section. (c) Determining the reduction (1) Reducing the out-of-pocket limit — (A) First, the plan's out-of-pocket limit (set under section 18022(c)(1)) is cut: by two-thirds for income 100 to 200 percent of poverty; by one-half for income 200 to 300 percent; and by one-third for income 300 to 400 percent. (B) But the Secretary must make sure this reduction doesn't push the plan's share of total costs above 94 percent (for the 100–150 percent group in paragraph (2)(A)), 87 percent (for the 150–200 percent group), 73 percent (for the 200–250 percent group), or 70 percent (for the 250–400 percent group) — adjusting the out-of-pocket limits as needed to keep those ceilings. (2) Extra reduction for lower incomes — The Secretary must require issuers to cut cost-sharing further so the plan pays: 94 percent of costs for income 100 to 150 percent of poverty; 87 percent for income 150 to 200 percent; and 73 percent for income 200 to 250 percent. (3) How reductions get paid — (A) The issuer tells the Secretary about its reductions, and the Secretary pays the issuer back periodically for their value. (B) The Secretary may set up a per-person ("capitated") payment system instead, adjusted for risk. (4) Additional benefits — If a plan, or a State requiring a plan, offers benefits beyond the required essential health benefits, this section's reductions don't apply to those extra benefits. (5) Pediatric dental — If someone buys both a qualified health plan and a separate pediatric dental plan, the cost-sharing reduction doesn't apply to the portion allocated to pediatric dental benefits. (d) Special rules for Indians (1) An Indian (as defined in 25 U.S.C. § 5304(d)) enrolled in an individual-market plan through an Exchange, with income at or below 300 percent of poverty, is treated as an eligible insured and gets all cost-sharing eliminated. (2) When an Indian gets an item or service directly from the Indian Health Service, a Tribe, a Tribal Organization, an Urban Indian Organization, or a referral through contract health services, no cost-sharing applies, and the issuer can't reduce its payment to that provider because of it. (3) The Secretary pays the issuer enough to cover the resulting increase in the plan's actuarial value. (e) People not lawfully present (1) If an otherwise-eligible insured is not lawfully present, they get no cost-sharing reduction, and their household income percentage of poverty is recalculated using a method that removes them from the family-size count in a specified way (or a comparable method reaching the same result). (2) Someone counts as "lawfully present" only if they are, and are expected to remain for the whole coverage period, a U.S. citizen, national, or lawfully present alien. (3) The Secretary, with the Secretary of the Treasury, must write rules for these calculations designed to place the least burden on applicants and taxpayers. (f) Special rule for 2021 unemployment compensation If someone received, or was approved to receive, unemployment compensation for any week in 2021, for that plan year: (1) they're treated as meeting the income floor in subsection (b)(2), and (2) any household income above 133 percent of poverty is ignored when applying subsections (c) and (d). (g) Definitions and special rules (1) Terms used here that are also used in section 36B of title 26 have the same meaning. (2) No cost-sharing reduction applies for a month unless the insured also qualifies for the premium tax credit under section 36B for that month. (3) Eligibility here is based on the tax year used for advance determinations under section 18082, not the year used for the section 36B credit itself.