42 U.S.C. § 18022 — Essential health benefits requirements

Page 9097 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18022 1 See References in Text note below. 2 So in original. Probably should be ‘‘paragraph,’’. 3 So in original. Probably should be ‘‘18031(d)(2)(B)(ii)’’. (Pub. L. 111–148, title I, § 1301, title X, § 10104(a), Mar. 23, 2010, 124 Stat. 162, 896.) Editorial Notes REFERENCES IN TEXT This title, where footnoted in text, is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which enacted this chapter and enacted, amended, and transferred nu- merous other sections and notes in the Code. For com- plete classification of title I to the Code, see Tables. AMENDMENTS 2010—Subsec. (a)(2) to (4). Pub. L. 111–148, § 10104(a), added pars. (2) to (4) and struck out former par. (2). Prior to amendment, text of par. (2) read as follows: ‘‘Any reference in this title to a qualified health plan shall be deemed to include a qualified health plan of- fered through the CO-OP program under section 18042 of this title or a community health insurance option under section 18043 of this title, unless specifically pro- vided for otherwise.’’ § 18022. Essential health benefits requirements (a) Essential health benefits package In this title,1 the term ‘‘essential health bene- fits package’’ means, with respect to any health plan, coverage that— (1) provides for the essential health benefits defined by the Secretary under subsection (b); (2) limits cost-sharing for such coverage in accordance with subsection (c); and (3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d). (b) Essential health benefits (1) In general Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories: (A) Ambulatory patient services. (B) Emergency services. (C) Hospitalization. (D) Maternity and newborn care. (E) Mental health and substance use dis- order services, including behavioral health treatment. (F) Prescription drugs. (G) Rehabilitative and habilitative serv- ices and devices. (H) Laboratory services. (I) Preventive and wellness services and chronic disease management. (J) Pediatric services, including oral and vision care. (2) Limitation (A) In general The Secretary shall ensure that the scope of the essential health benefits under para- graph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored cov- erage to determine the benefits typically covered by employers, including multiem- ployer plans, and provide a report on such survey to the Secretary. (B) Certification In defining the essential health benefits described in paragraph (1), and in revising the benefits under paragraph (4)(H), the Sec- retary shall submit a report to the appro- priate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2). (3) Notice and hearing In defining the essential health benefits de- scribed in paragraph (1), and in revising the benefits under paragraph (4)(H), the Secretary shall provide notice and an opportunity for public comment. (4) Required elements for consideration In defining the essential health benefits under paragraph (1), the Secretary shall— (A) ensure that such essential health bene- fits reflect an appropriate balance among the categories described in such subsection,2 so that benefits are not unduly weighted to- ward any category; (B) not make coverage decisions, deter- mine reimbursement rates, establish incen- tive programs, or design benefits in ways that discriminate against individuals be- cause of their age, disability, or expected length of life; (C) take into account the health care needs of diverse segments of the population, including women, children, persons with dis- abilities, and other groups; (D) ensure that health benefits established as essential not be subject to denial to indi- viduals against their wishes on the basis of the individuals’ age or expected length of life or of the individuals’ present or pre- dicted disability, degree of medical depend- ency, or quality of life; (E) provide that a qualified health plan shall not be treated as providing coverage for the essential health benefits described in paragraph (1) unless the plan provides that— (i) coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the require- ments or limitations that apply to emer- gency department services received from providers who do have such a contractual relationship with the plan; and (ii) if such services are provided out-of- network, the cost-sharing requirement (ex- pressed as a copayment amount or coinsur- ance rate) is the same requirement that would apply if such services were provided in-network; (F) provide that if a plan described in sec- tion 18031(b)(2)(B)(ii) 3 of this title (relating Page 9098 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18022 4 So in original. The word ‘‘and’’ probably should not appear. to stand-alone dental benefits plans) is of- fered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1)(J); and 4 (G) periodically review the essential health benefits under paragraph (1), and pro- vide a report to Congress and the public that contains— (i) an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost; (ii) an assessment of whether the essen- tial health benefits needs to be modified or updated to account for changes in medical evidence or scientific advancement; (iii) information on how the essential health benefits will be modified to address any such gaps in access or changes in the evidence base; (iv) an assessment of the potential of ad- ditional or expanded benefits to increase costs and the interactions between the ad- dition or expansion of benefits and reduc- tions in existing benefits to meet actuarial limitations described in paragraph (2); and (H) periodically update the essential health benefits under paragraph (1) to ad- dress any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under sub- paragraph (G). (5) Rule of construction Nothing in this title 1 shall be construed to prohibit a health plan from providing benefits in excess of the essential health benefits de- scribed in this subsection. (c) Requirements relating to cost-sharing (1) Annual limitation on cost-sharing (A) 2014 The cost-sharing incurred under a health plan with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223(c)(2)(A)(ii) of title 26 for self-only and family coverage, respectively, for taxable years beginning in 2014. (B) 2015 and later In the case of any plan year beginning in a calendar year after 2014, the limitation under this paragraph shall— (i) in the case of self-only coverage, be equal to the dollar amount under subpara- graph (A) for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment per- centage under paragraph (4) for the cal- endar year; and (ii) in the case of other coverage, twice the amount in effect under clause (i). If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (2) Repealed. Pub. L. 113–93, title II, § 213(a)(1), Apr. 1, 2014, 128 Stat. 1047 (3) Cost-sharing In this title— 1 (A) In general The term ‘‘cost-sharing’’ includes— (i) deductibles, coinsurance, copayments, or similar charges; and (ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d)(2) of title 26) with respect to essential health benefits covered under the plan. (B) Exceptions Such term does not include premiums, bal- ance billing amounts for non-network pro- viders, or spending for non-covered services. (4) Premium adjustment percentage For purposes of paragraph (1)(B)(i), the pre- mium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insur- ance coverage in the United States for the pre- ceding calendar year (as estimated by the Sec- retary no later than October 1 of such pre- ceding calendar year) exceeds such average per capita premium for 2013 (as determined by the Secretary). (d) Levels of coverage (1) Levels of coverage defined The levels of coverage described in this sub- section are as follows: (A) Bronze level A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan. (B) Silver level A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan. (C) Gold level A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the plan. (D) Platinum level A plan in the platinum level shall provide a level of coverage that is designed to pro- vide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan. (2) Actuarial value (A) In general Under regulations issued by the Secretary, the level of coverage of a plan shall be deter- Page 9099 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18022 mined on the basis that the essential health benefits described in subsection (b) shall be provided to a standard population (and with- out regard to the population the plan may actually provide benefits to). (B) Employer contributions The Secretary shall issue regulations under which employer contributions to a health savings account (within the meaning of section 223 of title 26) may be taken into account in determining the level of coverage for a plan of the employer. (C) Application In determining under this title,1 the Pub- lic Health Service Act [42 U.S.C. 201 et seq.], or title 26 the percentage of the total al- lowed costs of benefits provided under a group health plan or health insurance cov- erage that are provided by such plan or cov- erage, the rules contained in the regulations under this paragraph shall apply. (3) Allowable variance The Secretary shall develop guidelines to provide for a de minimis variation in the actu- arial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates. (4) Plan reference In this title,1 any reference to a bronze, sil- ver, gold, or platinum plan shall be treated as a reference to a qualified health plan pro- viding a bronze, silver, gold, or platinum level of coverage, as the case may be. (e) Catastrophic plan (1) In general A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of sub- section (d) with respect to any plan year if— (A) the only individuals who are eligible to enroll in the plan are individuals described in paragraph (2); and (B) the plan provides— (i) except as provided in clause (ii), the essential health benefits determined under subsection (b), except that the plan pro- vides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c)(1) for the plan year (except as provided for in section 2713); 1 and (ii) coverage for at least three primary care visits. (2) Individuals eligible for enrollment An individual is described in this paragraph for any plan year if the individual— (A) has not attained the age of 30 before the beginning of the plan year; or (B) has a certification in effect for any plan year under this title 1 that the indi- vidual is exempt from the requirement under section 5000A of title 26 by reason of— (i) section 5000A(e)(1) of such title (relat- ing to individuals without affordable cov- erage); or (ii) section 5000A(e)(5) of such title (re- lating to individuals with hardships). (3) Restriction to individual market If a health insurance issuer offers a health plan described in this subsection, the issuer may only offer the plan in the individual mar- ket. (f) Child-only plans If a qualified health plan is offered through the Exchange in any level of coverage specified under subsection (d), the issuer shall also offer that plan through the Exchange in that level as a plan in which the only enrollees are individ- uals who, as of the beginning of a plan year, have not attained the age of 21, and such plan shall be treated as a qualified health plan. (g) Payments to Federally-qualified health cen- ters If any item or service covered by a qualified health plan is provided by a Federally-qualified health center (as defined in section 1396d(l)(2)(B) of this title) to an enrollee of the plan, the offer- or of the plan shall pay to the center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1396a(bb) of this title) for such item or service. (Pub. L. 111–148, title I, § 1302, title X, § 10104(b), Mar. 23, 2010, 124 Stat. 163, 896; Pub. L. 113–93, title II, § 213(a), Apr. 1, 2014, 128 Stat. 1047.) Editorial Notes REFERENCES IN TEXT This title, referred to in subsecs. (a), (b)(5), (c)(3), (d)(2)(C), (4), and (e)(2)(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 classifica- tion of title I to the Code, see Tables. The Public Health Service Act, referred to in subsec. (d)(2)(C), is act July 1, 1944, ch. 373, 58 Stat. 682, which is classified generally to chapter 6A (§ 201 et seq.) of this title. For complete classification of this Act to the Code, see Short Title note set out under section 201 of this title and Tables. Section 2713, referred to in subsec. (e)(1)(B)(i), prob- ably means section 2713 of act July 1, 1944, which is classified to section 300gg–13 of this title. AMENDMENTS 2014—Subsec. (c)(2). Pub. L. 113–93, § 213(a)(1), struck out par. (2) which related to annual limitation on deductibles for employer-sponsored plans. Subsec. (c)(4). Pub. L. 113–93, § 213(a)(2), which di- rected amendment of par. (4)(A) by substituting ‘‘para- graph (1)(B)(i)’’ for ‘‘paragraphs (1)(B)(i) and (2)(B)(i)’’, was executed by making the substitution in par. (4) to reflect the probable intent of Congress. 2010—Subsec. (d)(2)(B). Pub. L. 111–148, § 10104(b)(1), substituted ‘‘shall issue’’ for ‘‘may issue’’. Subsec. (g). Pub. L. 111–148, § 10104(b)(2), added subsec. (g). Statutory Notes and Related Subsidiaries EFFECTIVE DATE OF 2014 AMENDMENT Amendment by Pub. L. 113–93 effective as if included in the enactment of Pub. L. 111–148, see section 213(c) of Pub. L. 113–93, set out as a note under section 300gg–6 of this title. Page 9100 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18023 1 See References in Text note below. 2 So in original. The word ‘‘shall’’ probably should not appear. § 18023. Special rules (a) State opt-out of abortion coverage (1) In general A State may elect to prohibit abortion cov- erage in qualified health plans offered through an Exchange in such State if such State enacts a law to provide for such prohibition. (2) Termination of opt out A State may repeal a law described in para- graph (1) and provide for the offering of such services through the Exchange. (b) Special rules relating to coverage of abortion services (1) Voluntary choice of coverage of abortion services (A) In general Notwithstanding any other provision of this title 1 (or any amendment made by this title)— 1 (i) nothing in this title 1 (or any amend- ment made by this title),1 shall be con- strued to require a qualified health plan to provide coverage of services described in subparagraph (B)(i) or (B)(ii) as part of its essential health benefits for any plan year; and (ii) subject to subsection (a), the issuer of a qualified health plan shall determine whether or not the plan provides coverage of services described in subparagraph (B)(i) or (B)(ii) as part of such benefits for the plan year. (B) Abortion services (i) Abortions for which public funding is prohibited The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Depart- ment of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the be- ginning of the plan year involved. (ii) Abortions for which public funding is allowed The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Depart- ment of Health and Human Services is per- mitted, based on the law as in effect as of the date that is 6 months before the begin- ning of the plan year involved. (2) Prohibition on the use of Federal funds (A) In general If a qualified health plan provides coverage of services described in paragraph (1)(B)(i), the issuer of the plan shall not use any amount attributable to any of the following for purposes of paying for such services: (i) The credit under section 36B of title 26 (and the amount (if any) of the advance payment of the credit under section 18082 of this title). (ii) Any cost-sharing reduction under section 18071 of this title (and the amount (if any) of the advance payment of the re- duction under section 18082 of this title). (B) Establishment of allocation accounts In the case of a plan to which subpara- graph (A) applies, the issuer of the plan shall— (i) collect from each enrollee in the plan (without regard to the enrollee’s age, sex, or family status) a separate payment for each of the following: (I) an amount equal to the portion of the premium to be paid directly by the enrollee for coverage under the plan of services other than services described in paragraph (1)(B)(i) (after reduction for credits and cost-sharing reductions de- scribed in subparagraph (A)); and (II) an amount equal to the actuarial value of the coverage of services de- scribed in paragraph (1)(B)(i), and (ii) shall 2 deposit all such separate pay- ments into separate allocation accounts as provided in subparagraph (C). In the case of an enrollee whose premium for coverage under the plan is paid through em- ployee payroll deposit, the separate pay- ments required under this subparagraph shall each be paid by a separate deposit. (C) Segregation of funds (i) In general The issuer of a plan to which subpara- graph (A) applies shall establish allocation accounts described in clause (ii) for enroll- ees receiving amounts described in sub- paragraph (A). (ii) Allocation accounts The issuer of a plan to which subpara- graph (A) applies shall deposit— (I) all payments described in subpara- graph (B)(i)(I) into a separate account that consists solely of such payments and that is used exclusively to pay for services other than services described in paragraph (1)(B)(i); and (II) all payments described in subpara- graph (B)(i)(II) into a separate account that consists solely of such payments and that is used exclusively to pay for services described in paragraph (1)(B)(i). (D) Actuarial value (i) In general The issuer of a qualified health plan shall estimate the basic per enrollee, per month cost, determined on an average ac- tuarial basis, for including coverage under the qualified health plan of the services described in paragraph (1)(B)(i). (ii) Considerations In making such estimate, the issuer— (I) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care;