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

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

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Source file: Laws/federal/codes/united-states-code/title-42/section-18041-state-flexibility-in-operation-and-enforcement-of-exchanges-and-related--162f453776.md
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Source location: Title 42, Chapter 157, § 18041; chapter-157-quality-affordable-health-care-for-all-americans.md

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**(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 general** — If— (A) a State is not an electing State under subsection (b); or (B) the Secretary determines, on or before January 1, 2013, that an electing State— (i) will not have any required Exchange operational by January 1, 2014; or (ii) has not taken the actions the Secretary determines necessary to implement— (I) the other requirements set forth in the standards under subsection (a); or (II) the requirements set forth in subtitles A and C and the amendments made by such subtitles; the Secretary shall (directly or through agreement with a not-for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements. (2) **Enforcement authority** — The provisions of section 2736(b) 1 of the Public Health Services 22 So in original. Probably should be “Service”. Act [[42 U.S.C. 300gg–22(b)](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–22/b&num=0&edition=prelim)] shall apply to the enforcement under paragraph (1) of requirements of subsection (a)(1) (without regard to any limitation on the application of those provisions to group health plans). **(d) No interference with State regulatory authority** Nothing in this title 1 shall be construed to preempt any State law that does not prevent the application of the provisions of this title.1 **(e) Presumption for certain State-operated Exchanges** (1) **In general** — In the case of a State operating an Exchange before January 1, 2010, and which has insured a percentage of its population not less than the percentage of the population projected to be covered nationally after the implementation of this Act, that seeks to operate an Exchange under this section, the Secretary shall presume that such Exchange meets the standards under this section unless the Secretary determines, after completion of the process established under paragraph (2), that the Exchange does not comply with such standards. (2) **Process** — The Secretary shall establish a process to work with a State described in paragraph (1) to provide assistance necessary to assist the State’s Exchange in coming into compliance with the standards for approval under this section.

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

42 U.S.C. § 201 — Funding

Beginning with fiscal year 2010, the Secretary shall transfer from the Public Health and Social Services Emergency Fund such sums as may be necessary to carry out this part.

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

42 U.S.C. § 300gg — Fair health insurance premiums

**(a) 11 So in original. No subsec. (b) has been enacted. Prohibiting discriminatory premium rates** (1) **In general** — With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market— (A) such rate shall vary with respect to the particular plan or coverage involved only by— (i) whether such plan or coverage covers an individual or family; (ii) rating area, as established in accordance with paragraph (2); (iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with [section 300gg–6(c) of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section300gg–6/c&num=0&edition=prelim)); and (iv) tobacco use, except that such rate shall not vary by more than 1.5 to 1; and (B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A). (2) **Rating area** (A) *In general* — Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this subchapter. (B) *Secretarial review* — The Secretary shall review the rating areas established by each State under subparagraph (A) to ensure the adequacy of such areas for purposes of carrying out the requirements of this subchapter. If the Secretary determines a State’s rating areas are not adequate, or that a State does not establish such areas, the Secretary may establish rating areas for that State. (3) **Permissible age bands** — The Secretary, in consultation with the National Association of Insurance Commissioners, shall define the permissible age bands for rating purposes under paragraph (1)(A)(iii). (4) **Application of variat

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

42 U.S.C. § 18043 — Funding for the territories

**(a) In general** A territory that— (1) elects consistent with subsection (b) to establish an Exchange in accordance with part B of this subchapter and establishes such an Exchange in accordance with such part shall be treated as a State for purposes of such part and shall be entitled to payment from the amount allocated to the territory under subsection (c); or (2) does not make such election shall be entitled to an increase in the dollar limitation applicable to the territory under subsections (f) and (g) of section 1108 of the Social Security Act ([42 U.S.C. 1308](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section1308&num=0&edition=prelim)) for such period in such amount for such territory and such increase shall not be taken into account in computing any other amount under such subsections. **(b) Terms and conditions** An election under subsection (a)(1) shall— (1) not be effective unless the election is consistent with [section 18041 of this title](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title42-section18041&num=0&edition=prelim) and is received not later than October 1, 2013; and (2) be contingent upon entering into an agreement between the territory and the Secretary that requires that— (A) funds provided under the agreement shall be used only to provide premium and cost-sharing assistance to residents of the territory obtaining health insurance coverage through the Exchange; and (B) the premium and cost-sharing assistance provided under such agreement shall be structured in such a manner so as to prevent any gap in assistance for individuals between the income level at which medical assistance is available through the territory’s Medicaid plan under title XIX of the Social Security Act [[42 U.S.C. 1396](

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

42 U.S.C. § 18041 — State flexibility in operation and en-

Page 9113 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18041 1 See References in Text note below. 2 So in original. Probably should be ‘‘Service’’. Statutory Notes and Related Subsidiaries TERMINATION OF PROVISION Pub. L. 111–148, title X, § 10104(j)(1), Mar. 23, 2010, 124 Stat. 901, provided that: ‘‘Subparagraph (B) of section 1313(a)(6) of this Act [42 U.S.C. 18033(a)(6)(B)] is hereby deemed null, void, and of no effect.’’ PART C—STATE FLEXIBILITY RELATING TO EXCHANGES § 18041. State flexibility in operation and en- forcement of Exchanges and related require- ments (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,1 and the amendments made by this title,1 with respect to— (A) the establishment and operation of Ex- changes (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 Sec- retary determines appropriate. The preceding sentence shall not apply to standards for requirements under subtitles A and C (and the amendments made by such sub- titles) for which the Secretary issues regula- tions under the Public Health Service Act [42 U.S.C. 201 et seq.]. (2) Consultation In issuing the regulations under paragraph (1), the Secretary shall consult with the Na- tional Association of Insurance Commis- sioners and its members and with health in- surance issuers, consumer organizations, and such other individuals as the Secretary selects in a manner designed to ensure balanced rep- resentation among interested parties. (b) State action Each Sta

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

42 U.S.C. § 201 — Definitions

Page 35 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 201 1 See References in Text note below. Sec. 300jj–34. Competitive grants to States and Indian tribes for the development of loan pro- grams to facilitate the widespread adoption of certified EHR technology. 300jj–35. Demonstration program to integrate in- formation technology into clinical education. 300jj–36. Information technology professionals in health care. 300jj–37. General grant and loan provisions. 300jj–38. Authorization for appropriations. PART C—OTHER PROVISIONS 300jj–51. Health information technology enroll- ment standards and protocols. 300jj–52. Information blocking. SUBCHAPTER XXIX—DATA COLLECTION, ANALYSIS, AND QUALITY 300kk. Data collection, analysis, and quality. SUBCHAPTER XXX—COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS 300ll to 300ll–9. Repealed. SUBCHAPTER XXXI—WORLD TRADE CENTER HEALTH PROGRAM PART A—ESTABLISHMENT OF PROGRAM; ADVISORY COMMITTEE 300mm. Establishment of World Trade Center Health Program. 300mm–1. WTC Health Program Scientific/Tech- nical Advisory Committee; WTC Health Program Steering Committees. 300mm–2. Education and outreach. 300mm–3. Uniform data collection and analysis. 300mm–4. Clinical Centers of Excellence and Data Centers. 300mm–5. Definitions. PART B—PROGRAM OF MONITORING, INITIAL HEALTH EVALUATIONS, AND TREATMENT SUBPART 1—WTC RESPONDERS 300mm–21. Identification of WTC responders and provision of WTC-related monitoring services. 300mm–22. Treatment of enrolled WTC responders for WTC-related health conditions. 300mm–23. National arrangement for benefits for el- igible individuals outside New York. SUBPART 2—WTC SURVIVORS 300mm–31. Identification and initial health evalua- tion of screening-eligible and

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

42 U.S.C. § 300gg — Fair health insurance premiums

Page 1597 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 300gg 1 So in original. 1 So in original. No subsec. (b) has been enacted. require the provision of data to public health authorities. (July 1, 1944, ch. 373, title XXVI, § 2695G, as added Pub. L. 111–87, § 13, Oct. 30, 2009, 123 Stat. 2902.) Statutory Notes and Related Subsidiaries EFFECTIVE DATE Section effective as if enacted on Sept. 30, 2009, see section 2(a)(3)(B) of Pub. L. 111–87, set out as an Effec- tive Date of 2009 Amendment; Revival of Section note under section 300ff–11 of this title. § 300ff–139. Injunctions regarding violation of prohibition (a) In general The Secretary may, in any court of competent jurisdiction, commence a civil action for the purpose of obtaining temporary or permanent injunctive relief with respect to any violation of this part. (b) Facilitation of information on violations The Secretary shall establish an administra- tive process for encouraging emergency response employees to provide information to the Sec- retary regarding violations of this part. As ap- propriate, the Secretary shall investigate al- leged such 1 violations and seek appropriate in- junctive relief. (July 1, 1944, ch. 373, title XXVI, § 2695H, as added Pub. L. 111–87, § 13, Oct. 30, 2009, 123 Stat. 2902.) Statutory Notes and Related Subsidiaries EFFECTIVE DATE Section effective as if enacted on Sept. 30, 2009, see section 2(a)(3)(B) of Pub. L. 111–87, set out as an Effec- tive Date of 2009 Amendment; Revival of Section note under section 300ff–11 of this title. § 300ff–140. Applicability of part This part shall not apply in a State if the chief executive officer of the State certifies to the Secretary that the law of the State is substan- tially consistent with this part. (July 1, 19

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