42 U.S.C. § 18002 — Reinsurance for early retirees

Page 9089 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18002 Medicaid coverage for up to 1 year postpartum, includ- ing through initiatives in Illinois, New Jersey, Vir- ginia, and Louisiana; (c) operating a Special Enrollment Period during 2021 that allowed 2.8 million Americans to newly enroll in coverage under the ACA; (d) extending the length of the HealthCare.gov Open Enrollment Period by 1 month and operating the most successful Open Enrollment Period ever, with a historic 14.5 million Americans enrolling in coverage through the ACA Marketplaces and an additional 1 million peo- ple enrolling in Basic Health Program coverage, result- ing in a 20 percent increase over the prior year across both programs combined; (e) increasing outreach and enrollment funding for organizations that help Americans apply for ACA and Medicaid coverage, including quadrupling the number of trained Navigators to more than 1,500 people in States using HealthCare.gov; (f) lowering maximum out-of-pocket costs for con- sumers with employer and ACA coverage by $400 in 2022; (g) reducing paperwork burdens for people enrolling in Medicaid and the ACA by eliminating unnecessary documentation requirements; (h) allowing low-income Americans to enroll in af- fordable ACA coverage year-round; (i) strengthening Medicaid and ACA section 1332 [42 U.S.C. 18052] waiver policies to partner with States to develop innovative coverage options, strengthen bene- fits, and lower costs; (j) proposing rules that would better ensure com- prehensive and standardized coverage and improve the adequacy of ACA provider networks; and (k) making efforts to improve the affordability of ACA coverage for families by proposing rules to correct a regulatory gap that prevents family members from accessing ACA subsidies despite very high premiums for coverage through an employer. On March 11, 2021, I signed into law the American Rescue Plan Act of 2021 (Public Law 117–2), which will further strengthen Medicaid and the ACA in numerous ways, including by making ACA coverage more afford- able for 9 million Americans through enhanced ACA subsidies, incentivizing States to adopt the ACA’s Med- icaid expansion, making it easier for States to extend postpartum Medicaid coverage, establishing new op- tions for States to establish mobile crisis intervention services teams to help provide services to Medicaid beneficiaries experiencing a behavioral health crisis, and increasing Medicaid funding for home- and commu- nity-based services to strengthen and expand access to services for millions of seniors and people with disabil- ities who need care as well as to help States strengthen their programs. My Administration has made significant progress in making healthcare more affordable and accessible to millions of Americans. From the end of 2020 to Sep- tember 2021, one in seven uninsured Americans gained coverage, leaving the uninsured rate at nearly an all- time low. Despite this progress, nearly 4 million Ameri- cans continue to be locked out of Medicaid expansion because they reside in 1 of the 12 States that have failed to adopt the ACA’s Medicaid expansion. In addi- tion, millions more continue to struggle to obtain the care they need, to go without health coverage, or to be enrolled in coverage that is insufficient to meet their needs. The effects of being uninsured or underinsured can be devastating financially, as families without ac- cess to affordable coverage may accrue high levels of medical debt. It remains the policy of my Administration to pro- tect and strengthen Medicaid and the ACA and to make high-quality healthcare accessible and affordable for every American. Agencies with authorities and respon- sibilities related to Medicaid and the ACA are con- tinuing their review of existing agency actions under Executive Order 14009. SEC. 2. Agency Responsibilities. In addition to taking the actions directed pursuant to Executive Order 14009, agencies (as described in section 3502(1) of title 44, United States Code, except for the agencies described in section 3502(5) of title 44, United States Code) with responsibilities related to Americans’ access to health coverage shall review agency actions to identify ways to continue to expand the availability of affordable health coverage, to improve the quality of coverage, to strengthen benefits, and to help more Americans enroll in quality health coverage. As part of this review, the heads of such agencies shall examine the following: (a) policies or practices that make it easier for all consumers to enroll in and retain coverage, understand their coverage options, and select appropriate cov- erage; (b) policies or practices that strengthen benefits and improve access to healthcare providers; (c) policies or practices that improve the comprehen- siveness of coverage and protect consumers from low- quality coverage; (d) policies or practices that expand eligibility and lower costs for coverage in the ACA Marketplaces, Medicaid, Medicare, and other programs; (e) policies or practices that help improve linkages between the healthcare system and other stakeholders to address health-related needs; and (f) policies or practices that help reduce the burden of medical debt on households. SEC. 3. 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 availability of appro- priations. (c) This order is not intended to, and does not, create any right or benefit, substantive or procedural, enforce- able at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person. J.R. BIDEN, JR. § 18002. Reinsurance for early retirees (a) Administration (1) In general Not later than 90 days after March 23, 2010, the Secretary shall establish a temporary re- insurance program to provide reimbursement to participating employment-based plans for a portion of the cost of providing health insur- ance coverage to early retirees (and to the eli- gible spouses, surviving spouses, and depend- ents of such retirees) during the period begin- ning on the date on which such program is es- tablished and ending on January 1, 2014. (2) Reference In this section: (A) Health benefits The term ‘‘health benefits’’ means med- ical, surgical, hospital, prescription drug, and such other benefits as shall be deter- mined by the Secretary, whether self-funded, or delivered through the purchase of insur- ance or otherwise. (B) Employment-based plan The term ‘‘employment-based plan’’ means a group benefits plan providing health bene- fits that— (i) is— (I) maintained by one or more current or former employers (including without Page 9090 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18002 limitation any State or local govern- ment or political subdivision thereof or any agency or instrumentality of any of the foregoing), employee organization, a voluntary employees’ beneficiary asso- ciation, or a committee or board of indi- viduals appointed to administer such plan; or (II) a multiemployer plan (as defined in section 1002(37) of title 29); and (ii) provides health benefits to early re- tirees. (C) Early retirees The term ‘‘early retirees’’ means individ- uals who are age 55 and older but are not eli- gible for coverage under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], and who are not active employees of an em- ployer maintaining, or currently contrib- uting to, the employment-based plan or of any employer that has made substantial contributions to fund such plan. (b) Participation (1) Employment-based plan eligibility A participating employment-based plan is an employment-based plan that— (A) meets the requirements of paragraph (2) with respect to health benefits provided under the plan; and (B) submits to the Secretary an applica- tion for participation in the program, at such time, in such manner, and containing such information as the Secretary shall re- quire. (2) Employment-based health benefits An employment-based plan meets the re- quirements of this paragraph if the plan— (A) implements programs and procedures to generate cost-savings with respect to par- ticipants with chronic and high-cost condi- tions; (B) provides documentation of the actual cost of medical claims involved; and (C) is certified by the Secretary. (c) Payments (1) Submission of claims (A) In general A participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain docu- mentation of the actual costs of the items and services for which each claim is being submitted. (B) Basis for claims Claims submitted under subparagraph (A) shall be based on the actual amount ex- pended by the participating employment- based plan involved within the plan year for the health benefits provided to an early re- tiree or the spouse, surviving spouse, or de- pendent of such retiree. In determining the amount of a claim for purposes of this sub- section, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefit. For purposes of determining the amount of any such claim, the costs paid by the early re- tiree or the retiree’s spouse, surviving spouse, or dependent in the form of deductibles, co-payments, or co-insurance shall be included in the amounts paid by the participating employment-based plan. (2) Program payments If the Secretary determines that a partici- pating employment-based plan has submitted a valid claim under paragraph (1), the Sec- retary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceed $15,000, subject to the limits contained in paragraph (3). (3) Limit To be eligible for reimbursement under the program, a claim submitted by a participating employment-based plan shall not be less than $15,000 nor greater than $90,000. Such amounts shall be adjusted each fiscal year based on the percentage increase in the Medical Care Com- ponent of the Consumer Price Index for all urban consumers (rounded to the nearest mul- tiple of $1,000) for the year involved. (4) Use of payments Amounts paid to a participating employ- ment-based plan under this subsection shall be used to lower costs for the plan. Such pay- ments may be used to reduce premium costs for an entity described in subsection (a)(2)(B)(i) or to reduce premium contribu- tions, co-payments, deductibles, co-insurance, or other out-of-pocket costs for plan partici- pants. Such payments shall not be used as gen- eral revenues for an entity described in sub- section (a)(2)(B)(i). The Secretary shall de- velop a mechanism to monitor the appropriate use of such payments by such entities. (5) Payments not treated as income Payments received under this subsection shall not be included in determining the gross income of an entity described in subsection (a)(2)(B)(i) that is maintaining or currently contributing to a participating employment- based plan. (6) Appeals The Secretary shall establish— (A) an appeals process to permit partici- pating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; and (B) procedures to protect against fraud, waste, and abuse under the program. (d) Audits The Secretary shall conduct annual audits of claims data submitted by participating employ- ment-based plans under this section to ensure that such plans are in compliance with the re- quirements of this section. (e) Funding There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise ap- propriated, $5,000,000,000 to carry out the pro- Page 9091 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18003 gram under this section. Such funds shall be available without fiscal year limitation. (f) Limitation The Secretary has the authority to stop tak- ing applications for participation in the pro- gram based on the availability of funding under subsection (e). (Pub. L. 111–148, title I, § 1102, title X, § 10102(a), Mar. 23, 2010, 124 Stat. 143, 892.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsec. (a)(2)(C), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Title XVIII of the Act is classified generally to subchapter XVIII (§ 1395 et seq.) of chapter 7 of this title. For com- plete classification of this Act to the Code, see section 1305 of this title and Tables. AMENDMENTS 2010—Subsec. (a)(2)(B). Pub. L. 111–148, § 10102(a)(1), substituted ‘‘group benefits plan providing health bene- fits’’ for ‘‘group health benefits plan’’ in introductory provisions. Subsec. (a)(2)(B)(i)(I). Pub. L. 111–148, § 10102(a)(2), in- serted ‘‘or any agency or instrumentality of any of the foregoing’’ after ‘‘political subdivision thereof’’. § 18003. Immediate information that allows con- sumers to identify affordable coverage op- tions (a) Internet portal to affordable coverage options (1) Immediate establishment Not later than July 1, 2010, the Secretary, in consultation with the States, shall establish a mechanism, including an Internet website, through which a resident of, or small business in, any State may identify affordable health insurance coverage options in that State. (2) Connecting to affordable coverage An Internet website established under para- graph (1) shall, to the extent practicable, pro- vide ways for residents of, and small busi- nesses in, any State to receive information on at least the following coverage options: (A) Health insurance coverage offered by health insurance issuers, other than cov- erage that provides reimbursement only for the treatment or mitigation of— (i) a single disease or condition; or (ii) an unreasonably limited set of dis- eases or conditions (as determined by the Secretary). (B) Medicaid coverage under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]. (C) Coverage under title XXI of the Social Security Act [42 U.S.C. 1397aa et seq.]. (D) A State health benefits high risk pool, to the extent that such high risk pool is of- fered in such State; and (E) Coverage under a high risk pool under section 18001 of this title. (F) Coverage within the small group mar- ket for small businesses and their employ- ees, including reinsurance for early retirees under section 18002 of this title, tax credits available under section 45R of title 26 (as added by section 1421), and other informa- tion specifically for small businesses regard- ing affordable health care options. (b) Enhancing comparative purchasing options (1) In general Not later than 60 days after March 23, 2010, the Secretary shall develop a standardized for- mat to be used for the presentation of infor- mation relating to the coverage options de- scribed in subsection (a)(2). Such format shall, at a minimum, require the inclusion of infor- mation on the percentage of total premium revenue expended on nonclinical costs (as re- ported under section 300gg–18(a) of this title), eligibility, availability, premium rates, and cost sharing with respect to such coverage op- tions and be consistent with the standards adopted for the uniform explanation of cov- erage as provided for in section 300gg–15 of this title. (2) Use of format The Secretary shall utilize the format devel- oped under paragraph (1) in compiling infor- mation concerning coverage options on the Internet website established under subsection (a). (c) Authority to contract The Secretary may carry out this section through contracts entered into with qualified entities. (Pub. L. 111–148, title I, § 1103, title X, § 10102(b), Mar. 23, 2010, 124 Stat. 146, 892.) Editorial Notes REFERENCES IN TEXT The Social Security Act, referred to in subsec. (a)(2)(B), (C), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Ti- tles XIX and XXI of the Act are classified generally to subchapters XIX (§ 1396 et seq.) and XXI (§ 1397aa et seq.), respectively, of chapter 7 of this title. For com- plete classification of this Act to the Code, see section 1305 of this title and Tables. Section 1421, referred to in subsec. (a)(2)(F), means section 1421 of Pub. L. 111–148. AMENDMENTS 2010—Subsec. (a)(1). Pub. L. 111–148, § 10102(b)(1), which directed insertion of ‘‘, or small business in,’’ after ‘‘residents of any’’, was executed by making the insertion after ‘‘resident of’’ to reflect the probable in- tent of Congress. Subsec. (a)(2). Pub. L. 111–148, § 10102(b)(2), added par. (2) and struck out former par. (2). Prior to amendment, text read as follows: ‘‘An Internet website established under paragraph (1) shall, to the extent practicable, provide ways for resi- dents of any State to receive information on at least the following coverage options: ‘‘(A) Health insurance coverage offered by health insurance issuers, other than coverage that provides reimbursement only for the treatment or mitigation of— ‘‘(i) a single disease or condition; or ‘‘(ii) an unreasonably limited set of diseases or conditions (as determined by the Secretary); ‘‘(B) Medicaid coverage under title XIX of the So- cial Security Act. ‘‘(C) Coverage under title XXI of the Social Secu- rity Act. ‘‘(D) A State health benefits high risk pool, to the extent that such high risk pool is offered in such State; and