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42 U.S.C. § 18063 — Risk adjustment

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

42 U.S.C. § 18063 — Risk adjustment

**(a) In general** (1) **Low actuarial risk plans** — 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title29-section1001&num=0&edition=prelim) et seq.]). (2) **High actuarial risk plans** — 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). **(b) Criteria and methods** 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](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395w-21&num=0&edition=prelim) et seq., 1395w–101 et seq.

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Source location: Title 42, Chapter 157, § 18063; chapter-157-quality-affordable-health-care-for-all-americans.md

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

29 U.S.C. § 1001 — Congressional findings and declaration of policy

**(a) Benefit plans as affecting interstate commerce and the Federal taxing power** The Congress finds that the growth in size, scope, and numbers of employee benefit plans in recent years has been rapid and substantial; that the operational scope and economic impact of such plans is increasingly interstate; that the continued well-being and security of millions of employees and their dependents are directly affected by these plans; that they are affected with a national public interest; that they have become an important factor affecting the stability of employment and the successful development of industrial relations; that they have become an important factor in commerce because of the interstate character of their activities, and of the activities of their participants, and the employers, employee organizations, and other entities by which they are established or maintained; that a large volume of the activities of such plans are carried on by means of the mails and instrumentalities of interstate commerce; that owing to the lack of employee information and adequate safeguards concerning their operation, it is desirable in the interests of employees and their beneficiaries, and to provide for the general welfare and the free flow of commerce, that disclosure be made and safeguards be provided with respect to the establishment, operation, and administration of such plans; that they substantially affect the revenues of the United States because they are afforded preferential Federal tax treatment; that despite the enormous growth in such plans many employees with long years of employment are losing anticipated retirement benefits owing to the lack of vesting provisions in such plans; that owing to the inadequacy of current minimum standards, the soundness and stabilit

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

42 U.S.C. § 1305 — Short title of chapter

This chapter may be cited as the “Social Security Act”.

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

42 U.S.C. § 18041 — State flexibility in operation and enforcement of Exchanges and related requirements

**(a) Establishment of standards** (1) **In general** — The Secretary shall, as soon as practicable after March 23, 2010, issue regulations setting standards for meeting the requirements under this title,11 See References in Text note below. and the amendments made by this title,1 with respect to— (A) the establishment and operation of Exchanges (including SHOP Exchanges); (B) the offering of qualified health plans through such Exchanges; (C) the establishment of the reinsurance and risk adjustment programs under part E; and (D) such other requirements as the Secretary determines appropriate. The preceding sentence shall not apply to standards for requirements under subtitles A and C (and the amendments made by such subtitles) for which the Secretary issues regulations under the Public Health Service Act [[42 U.S.C. 201](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section201&num=0&edition=prelim) et seq.]. (2) **Consultation** — In issuing the regulations under paragraph (1), the Secretary shall consult with the National Association of Insurance Commissioners and its members and with health insurance issuers, consumer organizations, and such other individuals as the Secretary selects in a manner designed to ensure balanced representation among interested parties. **(b) State action** Each State that elects, at such time and in such manner as the Secretary may prescribe, to apply the requirements described in subsection (a) shall, not later than January 1, 2014, adopt and have in effect— (1) the Federal standards established under subsection (a); or (2) a State law or regulation that the Secretary determines implements the standards within the State. **(c) Failure to establish Exchange or implement requirements** (1) **In gen

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

29 U.S.C. § 1001 — Congressional findings and declaration of

Page 353 TITLE 29—LABOR § 1001 Sec. 1365. Annual report of plan administrator. 1366. Annual notification to substantial employers. 1367. Recovery of liability for plan termination. 1368. Lien for liability. 1369. Treatment of transactions to evade liability; effect of corporate reorganization. 1370. Enforcement authority relating to termi- nations of single-employer plans. 1371. Penalty for failure to timely provide required information. SUBTITLE E—SPECIAL PROVISIONS FOR MULTIEMPLOYER PLANS PART 1—EMPLOYER WITHDRAWALS 1381. Withdrawal liability established; criteria and definitions. 1382. Determination and collection of liability; no- tification of employer. 1383. Complete withdrawal. 1384. Sale of assets. 1385. Partial withdrawals. 1386. Adjustment for partial withdrawal; deter- mination of amount; reduction for partial withdrawal liability; procedures applicable. 1387. Reduction or waiver of complete withdrawal liability; procedures and standards applica- ble. 1388. Reduction of partial withdrawal liability. 1389. De minimis rule. 1390. Nonapplicability of withdrawal liability for certain temporary contribution obligation periods; exception. 1391. Methods for computing withdrawal liability. 1392. Obligation to contribute. 1393. Actuarial assumptions. 1394. Application of plan amendments; exception. 1395. Plan notification to corporation of poten- tially significant withdrawals. 1396. Special rules for plans under section 404(c) of title 26. 1397. Application of part in case of certain pre-1980 withdrawals; adjustment of covered plan. 1398. Withdrawal not to occur because of change in business form or suspension of contribu- tions during labor dispute. 1399. Notice, collection, etc., of withdrawal liabil-

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

42 U.S.C. § 1395w — Payment of benefits

**(a) Amounts** Except as provided in [section 1395mm of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395mm&num=0&edition=prelim), and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are payable under this part, amounts equal to— (1) in the case of services described in [section 1395k(a)(1) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395k/a/1&num=0&edition=prelim)—80 percent of the reasonable charges for the services; except that (A) an organization which provides medical and other health services (or arranges for their availability) on a prepayment basis (and either is sponsored by a union or employer, or does not provide, or arrange for the provision of, any inpatient hospital services) may elect to be paid 80 percent of the reasonable cost of services for which payment may be made under this part on behalf of individuals enrolled in such organization in lieu of 80 percent of the reasonable charges for such services if the organization undertakes to charge such individuals no more than 20 percent of such reasonable cost plus any amounts payable by them as a result of subsection (b), (B) with respect to items and services described in [section 1395x(s)(10)(A) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395x/s/10/A&num=0&edition=prelim), the amounts paid shall be 100 percent of the reasonable charges for such items and services, (C) with respect to expenses incurred for those physicians

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

42 U.S.C. § 1395w — Appropriations to cover Government

Page 3243 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395w 1 See References in Text note below. mentary medical insurance program established under part B of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], and (2) provisions will be made for payment of the monthly premiums of such individuals for such program.’’ § 1395w. Appropriations to cover Government contributions and contingency reserve (a) In general There are authorized to be appropriated from time to time, out of any moneys in the Treasury not otherwise appropriated, to the Federal Sup- plementary Medical Insurance Trust Fund— (1)(A) a Government contribution equal to the aggregate premiums payable for a month for enrollees age 65 and over under this part and deposited in the Trust Fund, multiplied by the ratio of— (i) twice the dollar amount of the actuari- ally adequate rate per enrollee age 65 and over as determined under section 1395r(a)(1) of this title for such month minus the dollar amount of the premium per enrollee for such month, as determined under section 1395r(a)(3) of this title, to (ii) the dollar amount of the premium per enrollee for such month, plus (B) a Government contribution equal to the aggregate premiums payable for a month for enrollees under age 65 under this part and de- posited in the Trust Fund, multiplied by the ratio of— (i) twice the dollar amount of the actuari- ally adequate rate per enrollee under age 65 as determined under section 1395r(a)(4) of this title for such month minus the dollar amount of the premium per enrollee for such month, as determined under section 1395r(a)(3) of this title, to (ii) the dollar amount of the premium per enrollee for such month; minus (C) the aggregate amount of additional pre- mium payment

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

42 U.S.C. § 18063 — Risk adjustment

Page 9127 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18071 1 So in original. Probably should be followed by ‘‘be’’. 2 So in original. Probably should be ‘‘sections’’. the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs. (c) Definitions In this section: (1) Allowable costs (A) In general The amount of allowable costs of a plan for any year is an amount equal to the total costs (other than administrative costs) of the plan in providing benefits covered by the plan. (B) Reduction for risk adjustment and rein- surance payments Allowable costs shall 1 reduced by any risk adjustment and reinsurance payments re- ceived under section 2 18061 and 18063 of this title. (2) Target amount The target amount of a plan for any year is an amount equal to the total premiums (in- cluding any premium subsidies under any gov- ernmental program), reduced by the adminis- trative costs of the plan. (Pub. L. 111–148, title I, § 1342, Mar. 23, 2010, 124 Stat. 211.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsec. (a), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Part D of title XVIII of the Act is classified generally to part D (§ 1395w–101 et seq.) of subchapter XVIII of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables. § 18063. Risk adjustment (a) In general (1) Low actuarial risk plans 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 cov- erage) described in subsection (c) if t

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