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42 U.S.C. § 18033 — Financial integrity

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

42 U.S.C. § 18033 — Financial integrity

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Page 9112 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18033 1 See References in Text note below. 2 See Termination of Provision note below. Subsec. (f)(1)(A)(ii). Pub. L. 111–148, § 10104(i)(3), struck out ‘‘(except with respect to territorial agree- ments under this subsection)’’ before period at end. § 18033. Financial integrity (a) Accounting for expenditures (1) In general An Exchange shall keep an accurate ac- counting of all activities, receipts, and ex- penditures and shall annually submit to the Secretary a report concerning such account- ings. (2) Investigations The Secretary, in coordination with the In- spector General of the Department of Health and Human Services, may investigate the af- fairs of an Exchange, may examine the prop- erties and records of an Exchange, and may re- quire periodic reports in relation to activities undertaken by an Exchange. An Exchange shall fully cooperate in any investigation con- ducted under this paragraph. (3) Audits An Exchange shall be subject to annual au- dits by the Secretary. (4) Pattern of abuse If the Secretary determines that an Ex- change or a State has engaged in serious mis- conduct with respect to compliance with the requirements of, or carrying out of activities required under, this title,1 the Secretary may rescind from payments otherwise due to such State involved under this or any other Act ad- ministered by the Secretary an amount not to exceed 1 percent of such payments per year until corrective actions are taken by the State that are determined to be adequate by the Secretary. (5) Protections against fraud and abuse With respect to activities carried out under this title,1 the Secretary shall provide for the efficient and non-discriminatory administra- tion of Exchange activities and implement any measure or procedure that— (A) the Secretary determines is appro- priate to reduce fraud and abuse in the ad- ministration of this title; 1 and (B) the Secretary has authority to imple- ment under this title 1 or any other Act. (6) Application of the False Claims Act (A) In general Payments made by, through, or in connec- tion with an Exchange are subject to the False Claims Act (31 U.S.C. 3729 et seq.) if those payments include any Federal funds. Compliance with the requirements of this Act concerning eligibility for a health insur- ance issuer to participate in the Exchange shall be a material condition of an issuer’s entitlement to receive payments, including payments of premium tax credits and cost- sharing reductions, through the Exchange. (B) 2 Damages Notwithstanding paragraph (1) of section 3729(a) of title 31, and subject to paragraph (2) of such section, the civil penalty assessed under the False Claims Act on any person found liable under such Act as described in subparagraph (A) shall be increased by not less than 3 times and not more than 6 times the amount of damages which the Govern- ment sustains because of the act of that per- son. (b) GAO oversight Not later than 5 years after the first date on which Exchanges are required to be operational under this title,1 the Comptroller General shall conduct an ongoing study of Exchange activities and the enrollees in qualified health plans of- fered through Exchanges. Such study shall re- view— (1) the operations and administration of Ex- changes, including surveys and reports of qualified health plans offered through Ex- changes and on the experience of such plans (including data on enrollees in Exchanges and individuals purchasing health insurance cov- erage outside of Exchanges), the expenses of Exchanges, claims statistics relating to quali- fied health plans, complaints data relating to such plans, and the manner in which Ex- changes meet their goals; (2) any significant observations regarding the utilization and adoption of Exchanges; (3) where appropriate, recommendations for improvements in the operations or policies of Exchanges; (4) a survey of the cost and affordability of health care insurance provided under the Ex- changes for owners and employees of small business concerns (as defined under section 632 of title 15), including data on enrollees in Ex- changes and individuals purchasing health in- surance coverage outside of Exchanges; and (5) how many physicians, by area and spe- cialty, are not taking or accepting new pa- tients enrolled in Federal Government health care programs, and the adequacy of provider networks of Federal Government health care programs. (Pub. L. 111–148, title I, § 1313, title X, § 10104(k), Mar. 23, 2010, 124 Stat. 184, 902.) Editorial Notes REFERENCES IN TEXT This title, referred to in subsecs. (a)(4), (5) and (b), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables. This Act, referred to in subsec. (a)(4), (6)(A), is Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 119, known as the Pa- tient Protection and Affordable Care Act. For complete classification of this Act to the Code, see Short Title note set out under section 18001 of this title and Tables. The False Claims Act, referred to in subsec. (a)(6), was the popular name for sections 231, 232, 233, and 235 of former Title 31, Money and Finance. Sections 231, 232, 233, and 235 were repealed by Pub. L. 97–258, § 5(b), Sept. 13, 1982, 96 Stat. 1084, and reenacted by the first section thereof as sections 3729 to 3731 of Title 31, Money and Finance. AMENDMENTS 2010—Subsec. (b)(4), (5). Pub. L. 111–148, § 10104(k), added par. (4) and redesignated former par. (4) as (5). 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 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 Sec- retary 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 Sec- retary determines necessary to imple- ment— (I) the other requirements set forth in the standards under subsection (a); or (II) the requirements set forth in sub- titles A and C and the amendments made by such subtitles; the Secretary shall (directly or through agree- ment 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 re- quirements. (2) Enforcement authority The provisions of section 2736(b) 1 of the Pub- lic Health Services 2 Act [42 U.S.C. 300gg–22(b)] shall apply to the enforcement under para- graph (1) of requirements of subsection (a)(1) (without regard to any limitation on the ap- plication of those provisions to group health plans). (d) No interference with State regulatory author- ity 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 Ex- changes (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 implementa- tion of this Act, that seeks to operate an Ex- change under this section, the Secretary shall presume that such Exchange meets the stand- ards under this section unless the Secretary determines, after completion of the process es- tablished under paragraph (2), that the Ex- change 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 sec- tion. (Pub. L. 111–148, title I, § 1321, Mar. 23, 2010, 124 Stat. 186.) Editorial Notes REFERENCES IN TEXT This title, referred to in subsecs. (a)(1) and (d), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and trans- ferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables. Subtitles A and C, referred to in subsecs. (a)(1) and (c)(1)(B)(ii)(II), are subtitles A (§§ 1001–1004) and C (§§ 1201–1255), respectively, of title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, 154. Subtitle A enacted sec- tions 300gg–11 to 300gg–19, 300gg–93, and 300gg–94 of this

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

31 U.S.C. § 3729 — False claims

**(a) Liability for Certain Acts.—** (1) **In general.—** — Subject to paragraph (2), any person who— (A) knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval; (B) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim; (C) conspires to commit a violation of subparagraph (A), (B), (D), (E), (F), or (G); (D) has possession, custody, or control of property or money used, or to be used, by the Government and knowingly delivers, or causes to be delivered, less than all of that money or property; (E) is authorized to make or deliver a document certifying receipt of property used, or to be used, by the Government and, intending to defraud the Government, makes or delivers the receipt without completely knowing that the information on the receipt is true; (F) knowingly buys, or receives as a pledge of an obligation or debt, public property from an officer or employee of the Government, or a member of the Armed Forces, who lawfully may not sell or pledge property; or (G) knowingly makes, uses, or causes to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the Government, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, as adjusted by the Federal Civil Penalties Inflation Adjustment Act of 1990 ([28 U.S.C. 2461](https://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title28-section2461&num=0&edition=prelim) note; Public Law 104–410 11 So in original. Probably should be “101–410”.

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

31 U.S.C. § 3729 — False claims

Page 335 TITLE 31—MONEY AND FINANCE § 3729 1 So in original. Probably should be ‘‘101–410’’. costs of bringing a civil action for the debt if the plaintiff denies the debt or does not agree to the setoff; and (B) have a civil action brought if one has not already been brought. (c) If the Government loses a civil action to recover a debt or recovers less than the amount the Secretary withholds under this section, the Secretary shall pay the plaintiff the balance and interest of 6 percent for the time the money is withheld. (Pub. L. 97–258, Sept. 13, 1982, 96 Stat. 977; Pub. L. 104–316, title II, § 202(p), Oct. 19, 1996, 110 Stat. 3844.) HISTORICAL AND REVISION NOTES Revised Section Source (U.S. Code) Source (Statutes at Large) 3728(a) ..... 31:227(1st sentence words before semicolon). Mar. 3, 1875, ch. 149, 18 Stat. 481; restated Mar. 3, 1933, ch. 212, § 13, 47 Stat. 1516. 3728(b) ..... 31:227(1st sentence words after semi- colon, 2d, 3d sen- tences). 3728(c) ..... 31:227(last sen- tence). In the section, the words ‘‘of the United States’’ are omitted as unnecessary. In subsection (a), the words ‘‘final . . . recovered . . . duly allowed by legal authority’’, ‘‘for payment’’, and ‘‘in any manner, whether as principal or surety’’ are omitted as surplus. In subsection (b)(1), the words ‘‘due from the plaintiff to the United States’’ are omitted as surplus. In subsection (b)(2)(A), the words ‘‘of such judgment’’, ‘‘be sufficient to’’, and ‘‘charges and’’ are omitted as surplus. The words ‘‘of bringing a civil action’’ are sub- stituted for ‘‘in prosecuting the debt’’ for consistency in the revised title and with other titles of the United States Code. The words ‘‘of the United States to final judgment’’ and ‘‘to the United States’’ ar

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

42 U.S.C. § 18033 — Financial integrity

**(a) Accounting for expenditures** (1) **In general** — An Exchange shall keep an accurate accounting of all activities, receipts, and expenditures and shall annually submit to the Secretary a report concerning such accountings. (2) **Investigations** — The Secretary, in coordination with the Inspector General of the Department of Health and Human Services, may investigate the affairs of an Exchange, may examine the properties and records of an Exchange, and may require periodic reports in relation to activities undertaken by an Exchange. An Exchange shall fully cooperate in any investigation conducted under this paragraph. (3) **Audits** — An Exchange shall be subject to annual audits by the Secretary. (4) **Pattern of abuse** — If the Secretary determines that an Exchange or a State has engaged in serious misconduct with respect to compliance with the requirements of, or carrying out of activities required under, this title,11 See References in Text note below. the Secretary may rescind from payments otherwise due to such State involved under this or any other Act administered by the Secretary an amount not to exceed 1 percent of such payments per year until corrective actions are taken by the State that are determined to be adequate by the Secretary. (5) **Protections against fraud and abuse** — With respect to activities carried out under this title,1 the Secretary shall provide for the efficient and non-discriminatory administration of Exchange activities and implement any measure or procedure that— (A) the Secretary determines is appropriate to reduce fraud and abuse in the administration of this title; 1 and (B) the Secretary has authority to implement under this title 1 or any other Act. (6) **Application of the False Claims Act** (A) *In general

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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. § 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

**(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. § 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

Source: Supplied 2024 U.S. Code historical extraction · 42 U.S.C. § 300gg

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