§18021 — Title 42 The Public Health and Welfare | U.S. Code

Summary

Defines what a "qualified health plan" must be and who can offer one. A qualified health plan must be certified by each Exchange where it is sold, must provide the required essential health benefits package, and must be sold by an issuer that is licensed and in good standing in every State where it offers coverage. The issuer must offer at least one silver-level plan and one gold-level plan in each Exchange, must charge the same premium for a given plan whether sold through an Exchange, directly, or through an agent, and must follow rules set by the Secretary of Health and Human Services and by the Exchange. Qualified plans include CO‑OP and multi‑State plans, may offer coverage through an approved direct primary care medical home if coordinated and meeting Secretary criteria, and may vary premiums by rating area (see section 300gg(a)(2)). Health plan — means health insurance coverage and a group health plan. Health insurance coverage and health insurance issuer — meanings are given in section 300gg–91(b). Group health plan — meaning is given in section 300gg–91(a). Except as this title says, a "health plan" does not include a group health plan or a multiple employer welfare arrangement to the extent it is not subject to State insurance regulation under section 1144 of title 29.

Title 42, §18021

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

(a)In this title: 11 See References in Text note below.

(1)The term “qualified health plan” means a health plan that—

(A)has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 18031(c) of this title issued or recognized by each Exchange through which such plan is offered;

(B)provides the essential health benefits package described in section 18022(a) of this title; and

(C)is offered by a health insurance issuer that—

(i)is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title; 1

(ii)agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange;

(iii)agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and

(iv)complies with the regulations developed by the Secretary under section 18031(d) of this title and such other requirements as an applicable Exchange may establish.

(2)Any reference in this title 1 to a qualified health plan shall be deemed to include a qualified health plan offered through the CO–OP program under section 18042 of this title, and a multi-State plan under section 18054 of this title, unless specifically provided for otherwise.

(3)The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.

(4)A qualified health plan, including a multi-State qualified health plan, may as appropriate vary premiums by rating area (as defined in section 300gg(a)(2) of this title).

(b)In this title: 1

(1)(A)The term “health plan” means health insurance coverage and a group health plan.

(B)Except to the extent specifically provided by this title,1 the term “health plan” shall not include a group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to State insurance regulation under section 1144 of title 29.

(2)The terms “health insurance coverage” and “health insurance issuer” have the meanings given such terms by section 300gg–91(b) of this title.

(3)The term “group health plan” has the meaning given such term by section 300gg–91(a) of this title.

Notes & Related Subsidiaries

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 numerous other sections and notes in the Code. For complete 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 offered 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 provided for otherwise.”

§18021 Qualified Health Plan Defined