42 U.S.C. § 18052: Waiver for State innovation

Summary

A State can ask the Secretary for permission to ignore some federal rules about health coverage for plan years starting on or after January 1, 2017. The State must file the application when and how the Secretary requires. The application must describe the State law and program that will replace the federal rules, include a 10-year budget plan that is budget neutral for the Federal Government, and show the State has passed the needed law. The waiver can cover the federal parts listed for plan years beginning January 1, 2014, including Parts A and B of the subchapter, section 18071, and tax rules in sections 36B, 4980H, and 5000A. If the State’s plan means people or small employers would lose premium tax credits, cost-sharing reductions, or small business credits, the Secretary must calculate the total of those amounts and pay that money to the State each year. The Secretary must set rules (within 180 days after March 23, 2010) for public notice, comment, disclosure, State reporting, and evaluation, and must allow a State to seek one combined waiver that covers other federal health programs. The Secretary may approve a waiver only if the State plan will give coverage at least as comprehensive as section 18022(b), keep out-of-pocket costs at least as affordable, cover at least as many residents, and not increase the Federal deficit. The Secretary must decide within 180 days after getting the application and must tell the State (and Congress if denied) the decision and reasons. Waivers last up to 5 years; a State can ask to continue, and the request is treated as approved unless the Secretary denies it within 90 days or asks for more information. “Secretary” means HHS for Parts A–C and the Treasury for the tax rules.

Title 42, §18052

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

(a)Application

(1)In general

A State may apply to the Secretary for the waiver of all or any requirements described in paragraph (2) with respect to health insurance coverage within that State for plan years beginning on or after January 1, 2017. Such application shall—

(A)be filed at such time and in such manner as the Secretary may require;

(B)contain such information as the Secretary may require, including—

(i)a comprehensive description of the State legislation and program to implement a plan meeting the requirements for a waiver under this section; and

(ii)a 10-year budget plan for such plan that is budget neutral for the Federal Government; and

(C)provide an assurance that the State has enacted the law described in subsection (b)(2).

(2)Requirements

The requirements described in this paragraph with respect to health insurance coverage within the State for plan years beginning on or after January 1, 2014, are as follows:

(A)Part A of this subchapter.

(B)Part B of this subchapter.

(C)section 18071 of this title.

(D)section 36B, 4980H, and 5000A of title 26.

(3)Pass through of funding

With respect to a State waiver under paragraph (1), under which, due to the structure of the State plan, individuals and small employers in the State would not qualify for the premium tax credits, cost-sharing reductions, or small business credits under section 36B of title 26 or under part I of subtitle E for which they would otherwise be eligible, the Secretary shall provide for an alternative means by which the aggregate amount of such credits or reductions that would have been paid on behalf of participants in the Exchanges established under this title had the State not received such waiver, shall be paid to the State for purposes of implementing the State plan under the waiver. Such amount shall be determined annually by the Secretary, taking into consideration the experience of other States with respect to participation in an Exchange and credits and reductions provided under such provisions to residents of the other States.

(4)Waiver consideration and transparency

(A)In general

An application for a waiver under this section shall be considered by the Secretary in accordance with the regulations described in subparagraph (B).

(B)Regulations

Not later than 180 days after March 23, 2010, the Secretary shall promulgate regulations relating to waivers under this section that provide—

(i)a process for public notice and comment at the State level, including public hearings, sufficient to ensure a meaningful level of public input;

(ii)a process for the submission of an application that ensures the disclosure of—

(I)the provisions of law that the State involved seeks to waive; and

(II)the specific plans of the State to ensure that the waiver will be in compliance with subsection (b);

(iii)a process for providing public notice and comment after the application is received by the Secretary, that is sufficient to ensure a meaningful level of public input and that does not impose requirements that are in addition to, or duplicative of, requirements imposed under the Administrative Procedures Act,2 or requirements that are unreasonable or unnecessarily burdensome with respect to State compliance;

(iv)a process for the submission to the Secretary of periodic reports by the State concerning the implementation of the program under the waiver; and

(v)a process for the periodic evaluation by the Secretary of the program under the waiver.

(C)Report

The Secretary shall annually report to Congress concerning actions taken by the Secretary with respect to applications for waivers under this section.

(5)Coordinated waiver process

The Secretary shall develop a process for coordinating and consolidating the State waiver processes applicable under the provisions of this section, and the existing waiver processes applicable under titles XVIII, XIX, and XXI of the Social Security Act [42 U.S.C. 1395 et seq., 1396 et seq., 1397aa et seq.], and any other Federal law relating to the provision of health care items or services. Such process shall permit a State to submit a single application for a waiver under any or all of such provisions.

(6)Definition

In this section, the term “Secretary” means—

(A)the Secretary of Health and Human Services with respect to waivers relating to the provisions described in subparagraph (A) through (C) of paragraph (2); and

(B)the Secretary of the Treasury with respect to waivers relating to the provisions described in paragraph (2)(D).

(b)Granting of waivers

(1)In general

The Secretary may grant a request for a waiver under subsection (a)(1) only if the Secretary determines that the State plan—

(A)will provide coverage that is at least as comprehensive as the coverage defined in section 18022(b) of this title and offered through Exchanges established under this title 2 as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services based on sufficient data from the State and from comparable States about their experience with programs created by this Act and the provisions of this Act that would be waived;

(B)will provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this title 2 would provide;

(C)will provide coverage to at least a comparable number of its residents as the provisions of this title 2 would provide; and

(D)will not increase the Federal deficit.

(2)Requirement to enact a law

(A)In general

A law described in this paragraph is a State law that provides for State actions under a waiver under this section, including the implementation of the State plan under subsection (a)(1)(B).

(B)Termination of opt out

A State may repeal a law described in subparagraph (A) and terminate the authority provided under the waiver with respect to the State.

(c)Scope of waiver

(1)In general

The Secretary shall determine the scope of a waiver of a requirement described in subsection (a)(2) granted to a State under subsection (a)(1).

(2)Limitation

The Secretary may not waive under this section any Federal law or requirement that is not within the authority of the Secretary.

(d)Determinations by Secretary

(1)Time for determination

The Secretary shall make a determination under subsection (a)(1) not later than 180 days after the receipt of an application from a State under such subsection.

(2)Effect of determination

(A)Granting of waivers

If the Secretary determines to grant a waiver under subsection (a)(1), the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver.

(B)Denial of waiver

If the Secretary determines a waiver should not be granted under subsection (a)(1), the Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and the reasons therefore.

(e)Term of waiver

No waiver under this section may extend over a period of longer than 5 years unless the State requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of its submission to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination with respect to the request.

Notes & Related Subsidiaries

Editorial Notes

References in Text

Part I of subtitle E, referred to in subsec. (a)(3), is part I (§§ 1401–1415) of subtitle E of title I of Pub. L. 111–148, which enacted subchapter IV of this chapter and section 36B of Title 26, Internal Revenue Code, amended section 405 of this title, section 280C, 6103, and 7213 of Title 26, and section 1324 of Title 31, Money and Finance, and enacted provisions set out as a note under section 36B of Title 26. For complete classification of part I to the Code, see Tables. This title, where footnoted in subsecs. (a)(3) and (b)(1)(A) to (C), 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 Administrative Procedures Act, referred to in subsec. (a)(4)(B)(iii), probably means the Administrative Procedure Act, act June 11, 1946, ch. 324, 60 Stat. 237, which was classified to sections 1001 to 1011 of former title 5 and which was repealed and reenacted as subchapter II (§ 551 et seq.) of chapter 5, and chapter 7 (§ 701 et seq.), of Title 5, Government Organization and Employees, by Pub. L. 89–554, Sept. 6, 1966, 80 Stat. 378. See

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note preceding section 551 of Title 5. The Social Security Act, referred to in subsec. (a)(5), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Titles XVIII, XIX, and XXI of the Act are classified generally to subchapters XVIII (§ 1395 et seq.), XIX (§ 1396 et seq.), and XXI (§ 1397aa et seq.), respectively, of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables. This Act, referred to in subsec. (b)(1)(A), 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

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note set out under section 18001 of this title and Tables.

§18052 Waiver for State Innovation

Summary

Title 42, §18052

Notes & Related Subsidiaries

Editorial Notes

References in Text

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