§300gg–94 — Title 42 The Public Health and Welfare | U.S. Code

Summary

The Secretary of Health and Human Services must work with states to set up a yearly process, starting with the 2010 plan year, to check for unreasonable health insurance premium increases. Health insurers must give the Secretary and the state a written reason for any unreasonable increase before it starts and must post that information clearly on their websites. The Secretary must also make those reasons and related data available to the public. States that get federal grants must share information on premium trends and may recommend that a state Exchange stop using insurers that repeatedly raise premiums without good cause. Starting with plan years beginning in 2014, the Secretary and states must watch premium growth both inside and outside Exchanges; states must consider higher growth outside an Exchange when deciding whether to offer large-group plans through an Exchange. The Secretary will award grants to states for five years beginning in fiscal year 2010 to help review or approve increases, give information to the Secretary, and create nonprofit centers to collect and share payment data. Congress made $250,000,000 available for these grants, and any unused funds after fiscal year 2014 can be used for planning and implementing reforms. Grant amounts will be set by formula that considers number of plans and state population, with each state getting at least $1,000,000 and at most $5,000,000 per grant year. Beginning the first fiscal year after December 29, 2022, the Secretary will also award grants to states to enforce mental health and substance use parity if states apply and agree to review insurers’ required analyses; $10,000,000 is authorized for each of the first five fiscal years after December 29, 2022. Created centers must make fair fee schedules, use good statistical methods, update data, publish methods, offer public online cost information, keep independent bylaws free of conflicts, and cannot force insurers to give data.

Title 42, §300gg–94

The Public Health and Welfare — Source: USLM XML via OLRC

(a)(1)The Secretary, in conjunction with States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage.

(2)The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers.

(b)(1)As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall—

(A)provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and

(B)make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases.

(2)(A)Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange.

(B)In determining under section 18032(f)(2)(B) of this title whether to offer qualified health plans in the large group market through an Exchange, the State shall take into account any excess of premium growth outside of the Exchange as compared to the rate of such growth inside the Exchange.

(c)(1)The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including—

(A)in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage;

(B)in providing information and recommendations to the Secretary under subsection (b)(1); and

(C)in establishing centers (consistent with subsection (d)) at academic or other nonprofit institutions to collect medical reimbursement information from health insurance issuers, to analyze and organize such information, and to make such information available to such issuers, health care providers, health researchers, health care policy makers, and the general public.

(2)(A)Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B).

(B)If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A.

(C)The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula—

(i)the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and

(ii)no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.

(3)(A)Beginning during the first fiscal year that begins after December 29, 2022, the Secretary shall, out of funds made available pursuant to subparagraph (C), award grants to eligible States to enforce and ensure compliance with the mental health and substance use disorder parity provisions of section 300gg––26 of this title.

(B)A State shall be eligible for a grant awarded under this paragraph only if such State—

(i)submits to the Secretary an application for such grant at such time, in such manner, and containing such information as specified by the Secretary; and

(ii)agrees to request and review from health insurance issuers offering group or individual health insurance coverage the comparative analyses and other information required of such health insurance issuers under subsection (a)(8)(A) of section 300gg–26 of this title relating to the design and application of nonquantitative treatment limitations imposed on mental health or substance use disorder benefits.

(C)There are authorized to be appropriated $10,000,000 for each of the first five fiscal years beginning after December 29, 2022, to remain available until expended, for purposes of awarding grants under subparagraph (A).

(d)(1)A center established under subsection (c)(1)(C) shall—

(A)develop fee schedules and other database tools that fairly and accurately reflect market rates for medical services and the geographic differences in those rates;

(B)use the best available statistical methods and data processing technology to develop such fee schedules and other database tools;

(C)regularly update such fee schedules and other database tools to reflect changes in charges for medical services;

(D)make health care cost information readily available to the public through an Internet website that allows consumers to understand the amounts that health care providers in their area charge for particular medical services; and

(E)regularly publish information concerning the statistical methodologies used by the center to analyze health charge data and make such data available to researchers and policy makers.

(2)A center established under subsection (c)(1)(C) shall adopt by-laws that ensures that the center (and all members of the governing board of the center) is independent and free from all conflicts of interest. Such by-laws shall ensure that the center is not controlled or influenced by, and does not have any corporate relation to, any individual or entity that may make or receive payments for health care services based on the center’s analysis of health care costs.

(3)Nothing in this subsection shall be construed to permit a center established under subsection (c)(1)(C) to compel health insurance issuers to provide data to the center.

Notes & Related Subsidiaries

Editorial Notes

Prior Provisions

A prior section 2794 of act July 1, 1944, was renumbered section 2795 and is classified to section 300gg–95 of this title.

Amendments

2022—Subsec. (c)(3). Pub. L. 117–328 added par. (3). 2010—Subsec. (c)(1)(C). Pub. L. 111–148, § 10101(i)(1), added subpar. (C). Subsec. (d). Pub. L. 111–148, § 10101(i)(2), added subsec. (d).

Statutory Notes and Related Subsidiaries

Effective Date

Section effective for fiscal years beginning with fiscal year 2010, see section 1004(a) of Pub. L. 111–148, set out as a note under section 300gg–11 of this title. Section effective Mar. 23, 2010, see section 1004(b) of Pub. L. 111–148, set out as a note under section 300gg–11 of this title.

§300gg–94 Ensuring that consumers get value for their dollars