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42 U.S.C. § 18052 — Waiver for State innovation

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42 U.S.C. § 18052 — Waiver for State innovation

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Source location: Title 42, Chapter 157, § 18052; chapter-157-quality-affordable-health-care-for-all-americans.md

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**(a) Application** (1) **In general** — A State may apply to the Secretary for the waiver of all or any requirements described in paragraph (2) with respect to health insurance coverage within that State for plan years beginning on or after January 1, 2017. Such application shall— (A) be filed at such time and in such manner as the Secretary may require; (B) contain such information as the Secretary may require, including— (i) a comprehensive description of the State legislation and program to implement a plan meeting the requirements for a waiver under this section; and (ii) a 10-year budget plan for such plan that is budget neutral for the Federal Government; and (C) provide an assurance that the State has enacted the law described in subsection (b)(2). (2) **Requirements** — The requirements described in this paragraph with respect to health insurance coverage within the State for plan years beginning on or after January 1, 2014, are as follows: (A) Part A of this subchapter. (B) Part B of this subchapter. (C) [Section 18071 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18071&num=0&edition=prelim). (D) Sections 36B, 4980H, and 5000A of title 26. (3) **Pass through of funding** — With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under sections 11 So in original. Probably should be “section”. 36B of title 26 or under part I of subtitle E for which they would otherwise be eligible, the Secretary shall provide for an alternative means by which the aggregate amount of such credits or reductions that would have been paid on behalf of participants in the Exchanges established under this title 22 See References in Text note below. had the State not received such waiver, shall be paid to the State for purposes of implementing the State plan under the waiver. Such amount shall be determined annually by the Secretary, taking into consideration the experience of other States with respect to participation in an Exchange and credits and reductions provided under such provisions to residents of the other States. (4) **Waiver consideration and transparency** (A) *In general* — An application for a waiver under this section shall be considered by the Secretary in accordance with the regulations described in subparagraph (B). (B) *Regulations* — Not later than 180 days after March 23, 2010, the Secretary shall promulgate regulations relating to waivers under this section that provide— (i) a process for public notice and comment at the State level, including public hearings, sufficient to ensure a meaningful level of public input; (ii) a process for the submission of an application that ensures the disclosure of— (I) the provisions of law that the State involved seeks to waive; and (II) the specific plans of the State to ensure that the waiver will be in compliance with subsection (b); (iii) a process for providing public notice and comment after the application is received by the Secretary, that is sufficient to ensure a meaningful level of public input and that does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act,2 or requirements that are unreasonable or unnecessarily burdensome with respect to State compliance; (iv) a process for the submission to the Secretary of periodic reports by the State concerning the implementation of the program under the waiver; and (v) a process for the periodic evaluation by the Secretary of the program under the waiver. (C) *Report* — The Secretary shall annually report to Congress concerning actions taken by the Secretary with respect to applications for waivers under this section. (5) **Coordinated waiver process** — The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under titles XVIII, XIX, and XXI of the Social Security Act [[42 U.S.C. 1395](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1395&num=0&edition=prelim) et seq., 1396 et seq., 1397aa et seq.], and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions. (6) **Definition** — In this section, the term “Secretary” means— (A) the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (2); and (B) the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph (2)(D). **(b) Granting of waivers** (1) **In general** — The Secretary may grant a request for a waiver under subsection (a)(1) only if the Secretary determines that the State plan— (A) will provide coverage that is at least as comprehensive as the coverage defined in [section 18022(b) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18022/b&num=0&edition=prelim) and offered through Exchanges established under this title 2 as certified by Office 33 So in original. Probably should be preceded by “the”. of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the State and from comparable States about their experience with programs created by this Act and the provisions of this Act that would be waived; (B) will provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this title 2 would provide; (C) will provide coverage to at least a comparable number of its residents as the provisions of this title 2 would provide; and (D) will not increase the Federal deficit. (2) **Requirement to enact a law** (A) *In general* — A law described in this paragraph is a State law that provides for State actions under a waiver under this section, including the implementation of the State plan under subsection (a)(1)(B). (B) *Termination of opt out* — A State may repeal a law described in subparagraph (A) and terminate the authority provided under the waiver with respect to the State. **(c) Scope of waiver** (1) **In general** — The Secretary shall determine the scope of a waiver of a requirement described in subsection (a)(2) granted to a State under subsection (a)(1). (2) **Limitation** — The Secretary may not waive under this section any Federal law or requirement that is not within the authority of the Secretary. **(d) Determinations by Secretary** (1) **Time for determination** — The Secretary shall make a determination under subsection (a)(1) not later than 180 days after the receipt of an application from a State under such subsection. (2) **Effect of determination** (A) *Granting of waivers* — If the Secretary determines to grant a waiver under subsection (a)(1), the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver. (B) *Denial of waiver* — If the Secretary determines a waiver should not be granted under subsection (a)(1), the Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and the reasons therefore.44 So in original. Probably should be “therefor.” **(e) Term of waiver** No waiver under this section may extend over a period of longer than 5 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request.

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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.

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5 U.S.C. § 551 — Definitions

For the purpose of this subchapter— (1) “agency” means each authority of the Government of the United States, whether or not it is within or subject to review by another agency, but does not include— (A) the Congress; (B) the courts of the United States; (C) the governments of the territories or possessions of the United States; (D) the government of the District of Columbia; or except as to the requirements of [section 552 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title5-section552&num=0&edition=prelim)— (E) agencies composed of representatives of the parties or of representatives of organizations of the parties to the disputes determined by them; (F) courts martial and military commissions; (G) military authority exercised in the field in time of war or in occupied territory; or (H) functions conferred by sections 1738, 1739, 1743, and 1744 of title 12; subchapter II of chapter 471 of title 49; or sections 1884, 1891–1902, and former section 1641(b)(2), of title 50, appendix; 11 See References in Text note below. (2) “person” includes an individual, partnership, corporation, association, or public or private organization other than an agency; (3) “party” includes a person or agency named or admitted as a party, or properly seeking and entitled as of right to be admitted as a party, in an agency proceeding, and a person or agency admitted by an agency as a party for limited purposes; (4) “rule” means the whole or a part of an agency statement of general or particular applicability and future effect designed to implement, interpret, or prescribe law or policy or describing the organization, procedure, or practice requirements of an agency and includes the approval or prescription for the future of rates, wa

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

42 U.S.C. § 18001 — Immediate access to insurance for uninsured individuals with a preexisting condition

**(a) In general** Not later than 90 days after March 23, 2010, the Secretary shall establish a temporary high risk health insurance pool program to provide health insurance coverage for eligible individuals during the period beginning on the date on which such program is established and ending on January 1, 2014. **(b) Administration** (1) **In general** — The Secretary may carry out the program under this section directly or through contracts to eligible entities. (2) **Eligible entities** — To be eligible for a contract under paragraph (1), an entity shall— (A) be a State or nonprofit private entity; (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (C) agree to utilize contract funding to establish and administer a qualified high risk pool for eligible individuals. (3) **Maintenance of effort** — To be eligible to enter into a contract with the Secretary under this subsection, a State shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools during the year preceding the year in which such contract is entered into. **(c) Qualified high risk pool** (1) **In general** — Amounts made available under this section shall be used to establish a qualified high risk pool that meets the requirements of paragraph (2). (2) **Requirements** — A qualified high risk pool meets the requirements of this paragraph if such pool— (A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; (B) provides health insurance coverage— (i) in which the issuer’s share of the total allowed costs of benefits provided under such co

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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

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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

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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

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

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

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42 U.S.C. § 1395 — Conditions of participation for home health agencies; home health quality

**(a) Conditions of participation; protection of individual rights; notification of State entities; use of home health aides; medical equipment; individual’s plan of care; compliance with Federal, State, and local laws and regulations** The conditions of participation that a home health agency is required to meet under this subsection are as follows: (1) The agency protects and promotes the rights of each individual under its care, including each of the following rights: (A) The right to be fully informed in advance about the care and treatment to be provided by the agency, to be fully informed in advance of any changes in the care or treatment to be provided by the agency that may affect the individual’s well-being, and (except with respect to an individual adjudged incompetent) to participate in planning care and treatment or changes in care or treatment. (B) The right to voice grievances with respect to treatment or care that is (or fails to be) furnished without discrimination or reprisal for voicing grievances. (C) The right to confidentiality of the clinical records described in section 1395x(o)(3) of this title. (D) The right to have one’s property treated with respect. (E) The right to be fully informed orally and in writing (in advance of coming under the care of the agency) of— (i) all items and services furnished by (or under arrangements with) the agency for which payment may be made under this subchapter, (ii) the coverage available for such items and services under this subchapter, subchapter XIX, and any other Federal program of which the agency is reasonably aware, (iii) any charges for items and services not covered under this subchapter and any charges the individual may have to pay with respect to items and services furn

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42 U.S.C. § 1395 — Prohibition against any Federal inter-

Page 2893 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 1395a (i) shared savings and competitive bidding in FFS Medicare; (ii) use of MA-negotiated rates to set FFS Medicare rates; and (iii) novel approaches to information development and sharing that may enable markets to lower cost and improve quality for FFS Medicare beneficiaries. SEC. 10. Reducing Obstacles to Improved Patient Care. Within 1 year of the date of this order, the Secretary shall propose regulatory changes to the Medicare pro- gram to reduce the burden on providers and eliminate regulations that create inefficiencies or otherwise un- dermine patient outcomes. SEC. 11. Maximizing Freedom for Medicare Patients and Providers. (a) Within 180 days of the date of this order, the Secretary, in coordination with the Commissioner of Social Security, shall revise current rules or policies to preserve the Social Security retirement insurance benefits of seniors who choose not to receive benefits under Medicare Part A, and propose other administra- tive improvements to Medicare enrollment processes for beneficiaries. (b) Within 1 year of the date of this order, the Sec- retary shall identify and remove unnecessary barriers to private contracts that allow Medicare beneficiaries to obtain the care of their choice and facilitate the de- velopment of market-driven prices. SEC. 12. General Provisions. (a) Nothing in this order shall be construed to impair or otherwise affect: (i) the authority granted by law to an executive de- partment or agency, or the head thereof; or (ii) the functions of the Director of the Office of Man- agement and Budget relating to budgetary, administra- tive, or legislative proposals. (b) This order shall be implemented consistent with applicable law and subject to the

Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 1395

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

42 U.S.C. § 18052 — Waiver for State innovation

Page 9120 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18052 1 So in original. Probably should be ‘‘section’’. 2 See References in Text note below. erty line for the size of the family involved but who is not eligible for the Medicaid pro- gram under title XIX of the Social Security Act by reason of such alien status; (C) who is not eligible for minimum essen- tial coverage (as defined in section 5000A(f) of title 26) or is eligible for an employer- sponsored plan that is not affordable cov- erage (as determined under section 5000A(e)(2) of such title); and (D) who has not attained age 65 as of the beginning of the plan year. Such term shall not include any individual who is not a qualified individual under section 18032 of this title who is eligible to be covered by a qualified health plan offered through an Exchange. (2) Eligible individuals may not use Exchange An eligible individual shall not be treated as a qualified individual under section 18032 of this title eligible for enrollment in a qualified health plan offered through an Exchange es- tablished under section 18031 of this title. (f) Secretarial oversight The Secretary shall each year conduct a re- view of each State program to ensure compli- ance with the requirements of this section, in- cluding ensuring that the State program meets— (1) eligibility verification requirements for participation in the program; (2) the requirements for use of Federal funds received by the program; and (3) the quality and performance standards under this section. (g) Standard health plan offerors A State may provide that persons eligible to offer standard health plans under a basic health program established under this section may in- clude a licensed health maintenance organiza- tion, a lice

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