PRIA, Government Policy, Made Personal

Summary

People who qualify can sign up for any qualified health plan they are eligible for. Employers that use an Exchange can pick a level of coverage to offer, and each worker can choose any plan at that level. People who enroll may pay their premiums to the insurance company that sold the plan. Insurance companies must treat everyone they insure in the individual market as part of one single risk pool, and do the same for the small group market. A State may merge the individual and small-group markets if it wants. States cannot force grandfathered plans into those pools. Insurers may sell plans outside an Exchange, and people or employers may choose those plans. Exchanges cannot force anyone to enroll, and they cannot charge a penalty if someone cancels because they get minimum essential coverage (see section 5000A(f) of title 26) or that coverage becomes affordable (see section 36B(c)(2)(C)). Catastrophic plans are available only to people who meet the eligibility rules in section 18022(e)(2). After this subtitle starts, Members of Congress and their staff can only be offered plans created by this law or sold through an Exchange. States may let agents or brokers enroll people and help them get premium tax credits and cost-sharing reductions as soon as a plan is offered in the State. “Qualified individual” means someone seeking to enroll in an Exchange plan who lives in that State and is not incarcerated. “Qualified employer” means a small employer that offers Exchange plans to all full-time employees; beginning in 2017 a State may allow large employers to be treated the same. Noncitizens must be U.S. citizens, nationals, or lawfully present for the whole enrollment period to be treated as qualified.

Title 42, §18032

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

(a)Choice

(1)Qualified individuals

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

(2)Qualified employers

(A)Employer may specify level

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)Employee may choose plans within a level

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)Payment of premiums by qualified individuals

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)Single risk pool

(1)Individual market

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)Small group market

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)Merger of markets

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

(4)State law

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

(d)Empowering consumer choice

(1)Continued operation of market outside Exchanges

Nothing in this title 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)Continued operation of State benefit requirements

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)Voluntary nature of an Exchange

(A)Choice to enroll or not to enroll

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)Prohibition against compelled enrollment

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)Individuals allowed to enroll in any plan

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)Members of Congress in the Exchange

(i)Requirement

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)Definitions

In this section: (I) Member of Congress

(II)Congressional staff

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)No penalty for transferring to minimum essential coverage outside Exchange

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)Enrollment through agents or brokers

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)Qualified individuals and employers; access limited to citizens and lawful residents

(1)Qualified individuals

In this title: 1

(A)In general

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)Incarcerated individuals excluded

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)Qualified employer

In this title: 1

(A)In general

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)Extension to large groups

(i)In general

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)Large employers eligible

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)Access limited to lawful residents

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