42 U.S.C. § 18063 — Risk adjustment
submitted 16 years ago by Pub. L. 111-148 to r/title-42-THE-PUBLIC-HEALTH-AND-WELFARE · 343 words · no verdicts yet
Each State must adjust payments among individual and small-group health plans based on enrollee risk. Plans with lower-risk enrollees than the State average must pay a charge. Plans with higher-risk enrollees receive a payment instead.
(a) In general
(1) Low actuarial risk plans — Using criteria the Secretary* sets under subsection (b), each State* must charge health plans and insurers described in subsection (c) if their enrollees' health risk for a year is lower than the average risk across all plans and coverage in that State for that year (not counting self-insured group plans, which follow the Employee Retirement Income Security Act of 1974 instead).
(2) High actuarial risk plans — The same way, each State must pay health plans and insurers described in subsection (c) if their enrollees' health risk is higher than that State average.
(b) Criteria and methods
The Secretary, working with the States, sets the criteria and methods for this risk-adjustment work, and may borrow methods used in Medicare Part C or Part D. These criteria become part of the standards the Secretary issues under section 18041.
(c) Scope
This section covers a health plan* or insurer that sells coverage in the individual or small group market* within a State. It does not apply to a grandfathered health plan* or its issuer.
Using the criteria and methods developed under subsection (b), each State* shall assess a charge on health plans and health insurance issuers (with respect to health insurance coverage*) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all plans or coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1001 et seq.]).
Using the criteria and methods developed under subsection (b), each State shall provide a payment to health plans and health insurance issuers (with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).
The Secretary*, in consultation with States, shall establish criteria and methods to be used in carrying out the risk adjustment activities under this section. The Secretary may utilize criteria and methods similar to the criteria and methods utilized under part C or D of title XVIII of the Social Security Act [42 U.S.C. 1395w–21 et seq., 1395w–101 et seq.]. Such criteria and methods shall be included in the standards and requirements the Secretary prescribes under section 18041 of this title.
A health plan* or a health insurance issuer* is described in this subsection if such health plan or health insurance issuer provides coverage in the individual or small group market* within the State. This subsection shall not apply to a grandfathered health plan* or the issuer of a grandfathered health plan with respect to that plan.
Source credit: (Pub. L. 111–148, title I, § 1343, Mar. 23, 2010, 124 Stat. 212.)
- 2010Enacted · Pub. L. 111-148 · 124 Stat. 212
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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