§18032 — Title 42 The Public Health and Welfare | U.S. Code

Summary

People and small employers can pick and join any qualified health plan they are allowed to have through an Exchange. A small employer may choose a level of coverage to offer through the Exchange, and each eligible employee can pick a plan at that level. People can pay their own premiums to the insurance company. Insurers must treat everyone in their individual market plans (except grandfathered plans) as one single risk pool, and must do the same for their small group market plans. A State may merge the individual and small group markets if it wants. The law does not stop insurers from selling plans outside the Exchange, and it does not stop people or employers from choosing those plans. No one can be forced to enroll in a plan or in an Exchange. Catastrophic plans can only be chosen by people who meet the special eligibility rules. After the law takes effect, Members of Congress and their staff may only get plans created by or sold through the Exchange. Exchanges must not charge a fee if someone cancels because they become eligible for required coverage or the coverage becomes affordable. States can let agents or brokers enroll people and help them apply for premium tax credits and cost-sharing help as soon as a plan is offered in the State. Qualified individual: a person who wants to enroll in an individual-market plan through their State’s Exchange and who lives in that State; not eligible if incarcerated (except pre-trial) or not a U.S. citizen, national, or lawfully present. Qualified employer: a small employer that makes all full-time employees eligible for Exchange plans; after 2017 a State may let large employers do this too, in which case they count as qualified employers. Member of Congress: any Representative or Senator. Congressional staff: all full- and part-time employees in a Member’s official office, in or out of Washington, DC.

Title 42, §18032

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

(a)(1)A qualified individual may enroll in any qualified health plan available to such individual and for which such individual is eligible.

(2)(A)A qualified employer may provide support for coverage of employees under a qualified health plan by selecting any level of coverage under section 18022(d) of this title to be made available to employees through an Exchange.

(B)Each employee of a qualified employer that elects a level of coverage under subparagraph (A) may choose to enroll in a qualified health plan that offers coverage at that level.

(b)A qualified individual enrolled in any qualified health plan may pay any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan.

(c)(1)A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the individual market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.

(2)A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the small group market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.

(3)A State may require the individual and small group insurance markets within a State to be merged if the State determines appropriate.

(4)A State law requiring grandfathered health plans to be included in a pool described in paragraph (1) or (2) shall not apply.

(d)(1)Nothing in this title 11 See References in Text note below. shall be construed to prohibit—

(A)a health insurance issuer from offering outside of an Exchange a health plan to a qualified individual or qualified employer; and

(B)a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health plan offered outside of an Exchange.

(2)Nothing in this title 1 shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is offered outside of an Exchange to offer benefits.

(3)(A)Nothing in this title 1 shall be construed to restrict the choice of a qualified individual to enroll or not to enroll in a qualified health plan or to participate in an Exchange.

(B)Nothing in this title 1 shall be construed to compel an individual to enroll in a qualified health plan or to participate in an Exchange.

(C)A qualified individual may enroll in any qualified health plan, except that in the case of a catastrophic plan described in section 18022(e) of this title, a qualified individual may enroll in the plan only if the individual is eligible to enroll in the plan under section 18022(e)(2) of this title.

(D)(i)Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are—

(I)created under this Act (or an amendment made by this Act); or

(II)offered through an Exchange established under this Act (or an amendment made by this Act).

(ii)In this section:

(I)The term “Member of Congress” means any member of the House of Representatives or the Senate.

(II)The term “congressional staff” means all full-time and part-time employees employed by the official office of a Member of Congress, whether in Washington, DC or outside of Washington, DC.

(4)An Exchange, or a qualified health plan offered through an Exchange, shall not impose any penalty or other fee on an individual who cancels enrollment in a plan because the individual becomes eligible for minimum essential coverage (as defined in section 5000A(f) of title 26 without regard to paragraph (1)(C) or (D) thereof) or such coverage becomes affordable (within the meaning of section 36B(c)(2)(C) of such title).

(e)The Secretary shall establish procedures under which a State may allow agents or brokers—

(1)to enroll individuals and employers in any qualified health plans in the individual or small group market as soon as the plan is offered through an Exchange in the State; and

(2)to assist individuals in applying for premium tax credits and cost-sharing reductions for plans sold through an Exchange.

(f)(1)In this title: 1

(A)The term “qualified individual” means, with respect to an Exchange, an individual who—

(i)is seeking to enroll in a qualified health plan in the individual market offered through the Exchange; and

(ii)resides in the State that established the Exchange.

(B)An individual shall not be treated as a qualified individual if, at the time of enrollment, the individual is incarcerated, other than incarceration pending the disposition of charges.

(2)In this title: 1

(A)The term “qualified employer” means a small employer that elects to make all full-time employees of such employer eligible for 1 or more qualified health plans offered in the small group market through an Exchange that offers qualified health plans.

(B)(i)Beginning in 2017, each State may allow issuers of health insurance coverage in the large group market in the State to offer qualified health plans in such market through an Exchange. Nothing in this subparagraph shall be construed as requiring the issuer to offer such plans through an Exchange.

(ii)If a State under clause (i) allows issuers to offer qualified health plans in the large group market through an Exchange, the term “qualified employer” shall include a large employer that elects to make all full-time employees of such employer eligible for 1 or more qualified health plans offered in the large group market through the Exchange.

(3)If an individual is not, or is not reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan in the individual market that is offered through an Exchange.

Notes & Related Subsidiaries

Editorial Notes

References in Text

This title, referred to in subsecs. (d)(1), (2), (3)(A), (B) and (f)(1), (2), 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. The

Effective Date

of this subtitle, referred to in subsec. (d)(3)(D)(i), is the

Effective Date

of subtitle D of title I of Pub. L. 111–148, which is Mar. 23, 2010. This Act, referred to in subsec. (d)(3)(D)(i), is Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 119, known as the Patient 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.

Amendments

2010—Subsec. (a)(1). Pub. L. 111–148, § 10104(i)(1), inserted “and for which such individual is eligible” before period at end. Subsec. (e). Pub. L. 111–148, § 10104(i)(2)(B), struck out concluding provisions which read as follows: “Such procedures may include the establishment of rate schedules for broker commissions paid by health benefits plans offered through an exchange.” Subsec. (e)(1). Pub. L. 111–148, § 10104(i)(2)(A), inserted “and employers” after “enroll individuals”. Subsec. (f)(1)(A)(ii). Pub. L. 111–148, § 10104(i)(3), struck out “(except with respect to territorial agreements under this subsection)” before period at end.

§18032 Consumer Choice

Summary

Title 42, §18032

Notes & Related Subsidiaries

Editorial Notes

References in Text

Effective Date

Effective Date

Short Title

Amendments

Citations & Metadata