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42 U.S.C. § 18082 — Advance determination and payment of premium tax credits and cost-sharing reductions

Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 18082 — Advance determination and payment of premium tax credits and cost-sharing reductions

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Source file: Laws/federal/codes/united-states-code/title-42/section-18082-advance-determination-and-payment-of-premium-tax-credits-and-cost-sharin--a894047f88.md
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Source location: Title 42, Chapter 157, § 18082; chapter-157-quality-affordable-health-care-for-all-americans.md

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**(a) In general** The Secretary, in consultation with the Secretary of the Treasury, shall establish a program under which— (1) upon request of an Exchange, advance determinations are made under [section 18081 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18081&num=0&edition=prelim) with respect to the income eligibility of individuals enrolling in a qualified health plan in the individual market through the Exchange for the premium tax credit allowable under [section 36B of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B&num=0&edition=prelim) and the cost-sharing reductions under [section 18071 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18071&num=0&edition=prelim); (2) the Secretary notifies— (A) the Exchange and the Secretary of the Treasury of the advance determinations; and (B) the Secretary of the Treasury of the name and employer identification number of each employer with respect to whom 1 or more employee 11 So in original. Probably should be “employees”. of the employer were determined to be eligible for the premium tax credit under [section 36B of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B&num=0&edition=prelim) and the cost-sharing reductions under [section 18071 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18071&num=0&edition=prelim) 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 title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B/c/2/C&num=0&edition=prelim) to either be unaffordable to the employee or not provide the required minimum actuarial value; and (3) the Secretary of the Treasury makes advance payments of such credit or reductions to the issuers of the qualified health plans in order to reduce the premiums payable by individuals eligible for such credit. **(b) Advance determinations** (1) **In general** — The Secretary shall provide under the program established under subsection (a) that advance determination of eligibility with respect to any individual shall be made— (A) during the annual open enrollment period applicable to the individual (or such other enrollment period as may be specified by the Secretary); and (B) on the basis of the individual’s household income for the most recent taxable year for which the Secretary, after consultation with the Secretary of the Treasury, determines information is available. (2) **Changes in circumstances** — The Secretary shall provide procedures for making advance determinations on the basis of information other than that described in paragraph (1)(B) in cases where information included with an application form demonstrates substantial changes in income, changes in family size or other household circumstances, change in filing status, the filing of an application for unemployment benefits, or other significant changes affecting eligibility, including— (A) allowing an individual claiming a decrease of 20 percent or more in income, or filing an application for unemployment benefits, to have eligibility for the credit determined on the basis of household income for a later period or on the basis of the individual’s estimate of such income for the taxable year; and (B) the determination of household income in cases where the taxpayer was not required to file a return of tax imposed by this chapter for the second preceding taxable year. **(c) Payment of premium tax credits and cost-sharing reductions** (1) **In general** — The Secretary shall notify the Secretary of the Treasury and the Exchange through which the individual is enrolling of the advance determination under [section 18081 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18081&num=0&edition=prelim). (2) **Premium tax credit** (A) *In general* — The Secretary of the Treasury shall make the advance payment under this section of any premium tax credit allowed under [section 36B of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B&num=0&edition=prelim) to the issuer of a qualified health plan on a monthly basis (or such other periodic basis as the Secretary may provide). (B) *Issuer responsibilities* — An issuer of a qualified health plan receiving an advance payment with respect to an individual enrolled in the plan shall— (i) reduce the premium charged the insured for any period by the amount of the advance payment for the period; (ii) notify the Exchange and the Secretary of such reduction; (iii) include with each billing statement the amount by which the premium for the plan has been reduced by reason of the advance payment; and (iv) in the case of any nonpayment of premiums by the insured— (I) notify the Secretary of such nonpayment; and (II) allow a 3-month grace period for nonpayment of premiums before discontinuing coverage. (3) **Cost-sharing reductions** — The Secretary shall also notify the Secretary of the Treasury and the Exchange under paragraph (1) if an advance payment of the cost-sharing reductions under [section 18071 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18071&num=0&edition=prelim) is to be made to the issuer of any qualified health plan with respect to any individual enrolled in the plan. The Secretary of the Treasury shall make such advance payment at such time and in such amount as the Secretary specifies in the notice. **(d) No Federal payments for individuals not lawfully present** Nothing in this subtitle or the amendments made by this subtitle allows Federal payments, credits, or cost-sharing reductions for individuals who are not lawfully present in the United States. **(e) State flexibility** Nothing in this subtitle or the amendments made by this subtitle shall be construed to prohibit a State from making payments to or on behalf of an individual for coverage under a qualified health plan offered through an Exchange that are in addition to any credits or cost-sharing reductions allowable to the individual under this subtitle and such amendments.

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Federal law — U.S. Code and appendices · legal_authorities

31 U.S.C. § 1324 — Refund of internal revenue collections

**(a)** Necessary amounts are appropriated to the Secretary of the Treasury for refunding internal revenue collections as provided by law, including payment of— (1) claims for prior fiscal years; and (2) accounts arising under— (A) “Allowance or drawback (Internal Revenue)”; (B) “Redemption of stamps (Internal Revenue)”; (C) “Refunding legacy taxes, Act of March 30, 1928”; (D) “Repayment of taxes on distilled spirits destroyed by casualty”; and (E) “Refunds and payments of processing and related taxes”. **(b)** Disbursements may be made from the appropriation made by this section only for— (1) refunds to the limit of liability of an individual tax account; and (2) refunds due from credit provisions of the Internal Revenue Code of 1986 ([26 U.S.C. 1](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section1&num=0&edition=prelim) et seq.) enacted before January 1, 1978, or enacted by the Taxpayer Relief Act of 1997, or from section 21, 24, 25A, 35, 36, 36A,11 See References in Text note below. 36B, 168(k)(4)(F), 53(e),1 54B(h),1 3131, 3132, 3134, 6428, 6428A, 6428B, 6431,1 or 7527A of such Code, or due under section 3081(b)(2) of the Housing Assistance Tax Act of 2008.

Source: Supplied U.S. Code snapshot — release unconfirmed · 31 U.S.C. § 1324

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Federal law — U.S. Code and appendices · legal_authorities

26 U.S.C. § 36B — Refundable credit for coverage under a qualified health plan

**(a) In general** In the case of an applicable taxpayer, there shall be allowed as a credit against the tax imposed by this subtitle for any taxable year an amount equal to the premium assistance credit amount of the taxpayer for the taxable year. **(b) Premium assistance credit amount** For purposes of this section— (1) **In general** — The term “premium assistance credit amount” means, with respect to any taxable year, the sum of the premium assistance amounts determined under paragraph (2) with respect to all coverage months of the taxpayer occurring during the taxable year. (2) **Premium assistance amount** — The premium assistance amount determined under this subsection with respect to any coverage month is the amount equal to the lesser of— (A) the monthly premiums for such month for 1 or more qualified health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an Exchange established by the State under 1311 11 So in original. Probably should be preceded by “section”. of the Patient Protection and Affordable Care Act, or (B) the excess (if any) of— (i) the adjusted monthly premium for such month for the applicable second lowest cost silver plan with respect to the taxpayer, over (ii) an amount equal to 1/12 of the product of the applicable percentage and the taxpayer’s household income for the taxable year. (3) **Other terms and rules relating to premium assistance amounts** — For purposes of paragraph (2)— (A) *Applicable percentage* (i) *In general* — Except as provided in clause (ii), the applicable percentage for any taxable year shall be the percentage such that the applicable percentag

Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 36B

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 405 — Evidence, procedure, and certification for payments

**(a) Rules and regulations; procedures** The Commissioner of Social Security shall have full power and authority to make rules and regulations and to establish procedures, not inconsistent with the provisions of this subchapter, which are necessary or appropriate to carry out such provisions, and shall adopt reasonable and proper rules and regulations to regulate and provide for the nature and extent of the proofs and evidence and the method of taking and furnishing the same in order to establish the right to benefits hereunder. **(b) Administrative determination of entitlement to benefits; findings of fact; hearings; investigations; evidentiary hearings in reconsiderations of disability benefit terminations; subsequent applications** (1) The Commissioner of Social Security is directed to make findings of fact, and decisions as to the rights of any individual applying for a payment under this subchapter. Any such decision by the Commissioner of Social Security which involves a determination of disability and which is in whole or in part unfavorable to such individual shall contain a statement of the case, in understandable language, setting forth a discussion of the evidence, and stating the Commissioner’s determination and the reason or reasons upon which it is based. Upon request by any such individual or upon request by a wife, divorced wife, widow, surviving divorced wife, surviving divorced mother, surviving divorced father, husband, divorced husband, widower, surviving divorced husband, child, or parent who makes a showing in writing that his or her rights may be prejudiced by any decision the Commissioner of Social Security has rendered, the Commissioner shall give such applicant and such other individual reasonable notice and opportunity for a hearing with re

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 405

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Federal law — U.S. Code and appendices · legal_authorities

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

**(a) In general** In the case of an eligible insured enrolled in a qualified health plan— (1) the Secretary shall notify the issuer of the plan of such eligibility; and (2) the issuer shall reduce the cost-sharing under the plan at the level and in the manner specified in subsection (c). **(b) Eligible insured** In this section, the term “eligible insured” means an individual— (1) who enrolls in a qualified health plan in the silver level of coverage in the individual market offered through an Exchange; and (2) whose household income exceeds 100 percent but does not exceed 400 percent of the poverty line for a family of the size involved. In the case of an individual described in [section 36B(c)(1)(B) of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B/c/1/B&num=0&edition=prelim), the individual shall be treated as having household income equal to 100 percent for purposes of applying this section. **(c) Determination of reduction in cost-sharing** (1) **Reduction in out-of-pocket limit** (A) *In general* — The reduction in cost-sharing under this subsection shall first be achieved by reducing the applicable out-of pocket 11 So in original. Probably should be “out-of-pocket”. limit under [section 18022(c)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18022/c/1&num=0&edition=prelim) in the case of— (i) an eligible insured whose household income is more than 100 percent but not more than 200 percent of the poverty line for a family of the size involved, by two-thirds; (ii) an eligible insured whose household income is more than 200 percent but not more than 300 percent of the poverty line for a family of the size involved, by one-half; and (iii) an eligible in

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 18071

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 18081 — Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions

**(a) Establishment of program** The Secretary shall establish a program meeting the requirements of this section for determining— (1) whether an individual who is to be covered in the individual market by a qualified health plan offered through an Exchange, or who is claiming a premium tax credit or reduced cost-sharing, meets the requirements of sections 18032(f)(3), 18071(e), and 18082(d) of this title and [section 36B(e) of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B/e&num=0&edition=prelim) that the individual be a citizen or national of the United States or an alien lawfully present in the United States; (2) in the case of an individual claiming a premium tax credit or reduced cost-sharing under [section 36B of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section36B&num=0&edition=prelim) or [section 18071 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18071&num=0&edition=prelim)— (A) whether the individual meets the income and coverage requirements of such sections; and (B) the amount of the tax credit or reduced cost-sharing; (3) whether an individual’s coverage under an employer-sponsored health benefits plan is treated as unaffordable under sections 36B(c)(2)(C) and 5000A(e)(2) of title 26; 11 See References in Text note below. and (4) whether to grant a certification under [section 18031(d)(4)(H) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18031/d/4/H&num=0&edition=prelim) attesting that, for purposes of the individual responsibility requirement under [section 5000A of title 26](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title26-section5000A&num=0&edition=prelim), a

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 18081

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Federal law — U.S. Code and appendices · legal_authorities

26 U.S.C. § 35 — Health insurance costs of eligible individuals

**(a) In general** In the case of an individual, there shall be allowed as a credit against the tax imposed by subtitle A an amount equal to 72.5 percent of the amount paid by the taxpayer for coverage of the taxpayer and qualifying family members under qualified health insurance for eligible coverage months beginning in the taxable year. **(b) Eligible coverage month** For purposes of this section— (1) **In general** — The term “eligible coverage month” means any month if— (A) as of the first day of such month, the taxpayer— (i) is an eligible individual, (ii) is covered by qualified health insurance, the premium for which is paid by the taxpayer, (iii) does not have other specified coverage, and (iv) is not imprisoned under Federal, State, or local authority, and (B) such month begins more than 90 days after the date of the enactment of the Trade Act of 2002, and before January 1, 2022. (2) **Joint returns** — In the case of a joint return, the requirements of paragraph (1)(A) shall be treated as met with respect to any month if at least 1 spouse satisfies such requirements. **(c) Eligible individual** For purposes of this section— (1) **In general** — The term “eligible individual” means— (A) an eligible TAA recipient, (B) an eligible alternative TAA recipient, and (C) an eligible PBGC pension recipient. (2) **Eligible TAA recipient** (A) *In general* — Except as provided in subparagraph (B), the term “eligible TAA recipient” means, with respect to any month, any individual who is receiving for any day of such month a trade readjustment allowance under chapter 2 of title II of the Trade Act of 1974 or who would be eligible to receive such allowance if section 231 of such Act were applied without regard to subsection (a)(3)(

Source: Supplied U.S. Code snapshot — release unconfirmed · 26 U.S.C. § 35

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 1396w–3 — Enrollment simplification and coordination with State health insurance exchanges

**(a) Condition for participation in Medicaid** As a condition of the State plan under this subchapter and receipt of any Federal financial assistance under [section 1396b(a) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1396b/a&num=0&edition=prelim) for calendar quarters beginning after January 1, 2014, a State shall ensure that the requirements of subsection (b) is 11 So in original. Probably should be “are”. met. **(b) Enrollment simplification and coordination with State health insurance exchanges and CHIP** (1) **In general** — A State shall establish procedures for— (A) enabling individuals, through an Internet website that meets the requirements of paragraph (4), to apply for medical assistance under the State plan or under a waiver of the plan, to be enrolled in the State plan or waiver, to renew their enrollment in the plan or waiver, and to consent to enrollment or reenrollment in the State plan through electronic signature; (B) enrolling, without any further determination by the State and through such website, individuals who are identified by an Exchange established by the State under [section 18031 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18031&num=0&edition=prelim) as being eligible for— (i) medical assistance under the State plan or under a waiver of the plan; or (ii) child health assistance under the State child health plan under subchapter XXI; (C) ensuring that individuals who apply for but are determined to be ineligible for medical assistance under the State plan or a waiver or ineligible for child health assistance under the State child health plan under subchapter XXI, are screened for eligibility for enrollment in qualified health pl

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 1396w–3

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 18023 — Special rules

**(a) State opt-out of abortion coverage** (1) **In general** — A State may elect to prohibit abortion coverage in qualified health plans offered through an Exchange in such State if such State enacts a law to provide for such prohibition. (2) **Termination of opt out** — A State may repeal a law described in paragraph (1) and provide for the offering of such services through the Exchange. **(b) Special rules relating to coverage of abortion services** (1) **Voluntary choice of coverage of abortion services** (A) *In general* — Notwithstanding any other provision of this title 11 See References in Text note below. (or any amendment made by this title)— 1 (i) nothing in this title 1 (or any amendment made by this title),1 shall be construed to require a qualified health plan to provide coverage of services described in subparagraph (B)(i) or (B)(ii) as part of its essential health benefits for any plan year; and (ii) subject to subsection (a), the issuer of a qualified health plan shall determine whether or not the plan provides coverage of services described in subparagraph (B)(i) or (B)(ii) as part of such benefits for the plan year. (B) *Abortion services* (i) *Abortions for which public funding is prohibited* — The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. (ii) *Abortions for which public funding is allowed* — The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effe

Source: Supplied U.S. Code snapshot — release unconfirmed · 42 U.S.C. § 18023

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Federal law — U.S. Code and appendices · legal_authorities

42 U.S.C. § 18082 — Advance determination and payment of

Page 9134 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18082 4 So in original. Probably should be ‘‘on’’. 1 So in original. Probably should be ‘‘employees’’. (3) Limitations on liens and levies The Secretary (or, if applicable, the Attor- ney General of the United States) shall not— (A) file notice of lien with respect to any property of a person by reason of any failure to pay the penalty imposed by this sub- section; or (B) levy on any such property with respect to such failure. (i) Study of administration of employer responsi- bility (1) In general The Secretary of Health and Human Serv- ices shall, in consultation with the Secretary of the Treasury, conduct a study of the proce- dures that are necessary to ensure that in the administration of this title 1 and section 4980H of title 26 (as added by section 1513) 1 that the following rights are protected: (A) The rights of employees to preserve their right to confidentiality of their tax- payer return information and their right to enroll in a qualified health plan through an Exchange if an employer does not provide af- fordable coverage. (B) The rights of employers to adequate due process and access to information nec- essary to accurately determine any payment assessed on employers. (2) Report Not later than January 1, 2013, the Secretary of Health and Human Services shall report the results of the study conducted under para- graph (1), including any recommendations for legislative changes, to the Committees on Fi- nance and Health, Education, Labor and Pen- sions of the Senate and the Committees of 4 Education and Labor and Ways and Means of the House of Representatives. (Pub. L. 111–148, title I, § 1411, Mar. 23, 2010, 124 Stat. 224; Pub. L. 114–255, div. C, title XVIII, § 18001(a)(6)(B)

Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 18082

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