individuals not eligible for Medicaid (as modified by sec. 10104)
Establishment of program and eligibility. Requires the Secretary to establish a basic health program meeting the requirements of this section under which a state may enter into contracts to offer one or more standard health plans providing at least the essential health benefits to eligible individuals in lieu of offering such individuals coverage through an Exchange. Defines an eligible individual as a state resident not eligible to enroll in Medicaid for benefits that, at a minimum, consist of the essential health benefits; whose household income is between 133% and 200% of the poverty line for the size of the family involved; who is not eligible for minimum essential coverage (see below) or is eligible for an employer-sponsored plan that is not affordable coverage (see below); and who has not attained age 65 as of the beginning of the plan year. Prohibits an eligible individual from using a state Exchange. Makes legal immigrants whose income is less than 133% of the federal poverty level (FPL), and who are not eligible for Medicaid by virtue of the five year waiting period, eligible for the basic health program.
Certification as to benefit coverage and costs. Requires the state to establish to the satisfaction of the Secretary that for an eligible individual enrolled in a standard health plan offered through the program, the state provides that the monthly premium (after reduction for any premium tax credits and cost-sharing reductions allowable with respect to either plan) an eligible individual is required to pay does not exceed the amount of the monthly premium that the individual would have been required to pay (in the rating area
in which the individual resides) if enrolled in the applicable second lowest cost silver plan offered through an Exchange; and that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed that required under a platinum plan in the case of an eligible individual with household income not in excess of 150% of the poverty line for the size of the family involved; and the cost-sharing required under a gold plan in the case of any other eligible individual; and the benefits provided under the standard health plans offered through the program cover at least the essential health benefits.
Standard health plan. Defines a “standard heath plan” as one that the state contracts with under which the only individuals eligible to enroll are eligible individuals; that provides at least the essential health benefits; and, in the case of a plan that provides coverage offered by a health insurance issuer, has a medical loss ratio of at least 85%.
Contracting process. Requires a state basic health program to establish a competitive process for entering into contracts with standard health plans, including negotiation of premiums and cost-sharing and negotiation of benefits in addition to the essential health benefits. Requires a state, as part of its competitive process, to include specific
requirements including innovative features (e.g., care coordination and care
management for enrollees); consideration of, and the making of suitable allowances for, differences in health care needs of enrollees and differences in local availability of, and access to, health care providers (but does not allow discrimination on the basis of pre- existing conditions or other health status-related factors); managed care; and
performance measures. Requires a state, to the maximum extent feasible, to make multiple standard health plans available to eligible individuals to ensure individuals have a choice of such plans. Permits a state to negotiate regional compacts with other states to include coverage of eligible individuals. Requires a state to seek to coordinate the administration of, and provision of benefits under, its program with Medicaid, CHIP and other state-administered health programs to maximize the efficiency of such programs and to improve the continuity of care.
Transfer of funds to states. Requires the Secretary to transfer to the state with an eligible program for each fiscal year for which one or more standard health plans are operating within the state an amount equal to 95% of the premium tax credits and the cost-sharing reductions that would have been provided for the fiscal year to eligible individuals
enrolled in standard health plans in the state if such eligible individuals were allowed to enroll in QHPs through an Exchange. Requires a state to establish a trust for the deposit of the amounts received and provides such amounts only be used to reduce the
premiums and cost-sharing of, or to provide additional benefits for, eligible individuals enrolled in standard health plans within the state. Requires the Secretary to make funding amounts available on a per enrollee basis, taking into account specified factors, and take into consideration the experience of other states with respect to participation in an Exchange and such credits and reductions provided to residents of the other states, with a special focus on enrollees with income below 200% of poverty. Requires the CMS Actuary, in consultation with the Office of Tax Analysis of the Department of the
Treasury, to certify the methodology used to make determinations.
Abortion. Applies the bill’s limitations on coverage of abortion-related services to a state basic health program in the same manner as such rules apply to QHPs.
Secretarial oversight. Requires the Secretary to conduct annually a review of each state program to ensure compliance.
Effective 3/23/2010.
Sec. 1332. Waiver for State innovation.
Application. Permits a state to apply to the Secretary for the waiver of all or any specified requirements with respect to health insurance coverage within that state for plan years beginning on or after 1/1/2017. Requires the waiver application to include a
comprehensive description of the state legislation and program to implement a plan meeting the waiver requirements and a 10-year budget that is budget neutral for the federal government. Applies the Act’s requirements relating to essential benefits, affordable choices of plans and consumer choice, cost-sharing requirements, the refundable credits for premiums, and employer and individual responsibility requirements.
Pass through of funding. Provides that with respect to a state waiver, under which (due to the structure of the state plan), individuals and small employers in the state would not qualify for the Act’s premium tax credits, cost-sharing reductions, or small business credits or which they would otherwise be eligible, the Secretary must provide for an alternative means by which the aggregate amount of such credits or reductions are paid to the state. Requires such amount to 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.
Waiver consideration and transparency. Requires a waiver application to be considered by the Secretary in accordance with specified regulations.
Regulations and reporting. Within 180 days of enactment, requires the Secretary to promulgate regulations relating to waivers that provide procedures for: public notice and comment at the state level; the submission of an application that ensures the disclosure of the provisions of law that the state involved seeks to waive and the specific plans of the state to ensure that the waiver will be in compliance with requirements; a process for providing public notice and comment after the application is received by the Secretary; a process for submission to the Secretary of periodic reports by the state concerning the implementation of the program under the waiver; and a process for the periodic
evaluation by the Secretary of the program under the waiver. Requires the Secretary to annually report to Congress concerning actions taken by the Secretary with respect to applications for waivers under this section.
Coordinated waiver process. Requires the Secretary to develop a process for coordinating and consolidating the state waiver processes and the existing waiver processes applicable under Medicare, Medicaid, CHIP and any other Federal law relating to the provision of health care items or services. Requires this process to permit a state to submit a single application for a waiver under any or all of such provisions.
Granting of Waivers. Requires the Secretary to grant a request for a waiver only upon determining that the state plan will provide coverage at least as comprehensive as the essential benefits coverage offered through Exchanges as certified by the CMS Actuary; 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 would provide; will provide coverage to at least a comparable number of its residents as the provisions of this title would provide; and will not increase the federal deficit.
Scope of waiver and determinations by Secretary. Requires the Secretary to determine the scope of a waiver but may not waive any federal law or requirement that is not within the authority of the Secretary. Requires the determination within 180 days after the receipt of an application from a state. Requires notice of a favorable decision and the terms and effectiveness of such waiver. Requires that if the Secretary determines a waiver should not be granted, he or she notify the state and the appropriate committees of Congress and provide the reasons.
Term of waiver. Prohibits a waiver for longer than 5 years unless the state requests continuation; such request must 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.
Effective 3/23/2010.
Sec. 1333. Provisions relating to offering of plans in more than one State (as modified by sec. 10104).
Health care choice compacts. Effective 1/1/2016, two or more states may form Health Care Choice Compacts to facilitate the purchase of individual health insurance coverage across state lines. Requires the Secretary, by 7/1/2013, in consultation with the NAIC, to issue regulations for the creation of compacts under which one or more QHPs can be offered in the individual markets in all participating states but, except as specified, only be subject to the laws and regulations of the state in which the plan is written or issued. Subjects the issuer of any QHP to which the compact applies to the following laws of the state in which the purchaser resides: market conduct, unfair trade practices, network adequacy, and consumer protection standards (including rating standards), including addressing disputes as to the performance of the contract. Requires the issuer to be licensed in each state in which it offers the plan under the compact or to submit to the jurisdiction of each such state with regard to the above standards (including allowing access to records as if the insurer were licensed in the state) and to clearly notify consumers that the policy may not be subject to all the laws and regulations of the state in which the purchaser resides. Prohibits a state from entering into an agreement unless it enacts a law (after the date of this bill’s enactment) that specifically authorizes the state to enter into such agreements.
Approval of contracts. Permits the Secretary to approve compacts only if the Secretary determines that the compact will: 1) provide the essential benefits coverage offered through Exchanges; 2) provide coverage and cost sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this title would provide; 3) provide coverage to at least a comparable number of its residents as the provisions of this title would provide; 4) not increase the federal deficit; and 5) not weaken enforcement of insurance laws and regulations (described above) in any state that is included in such compact.
Sec. 1334 Multi-state plans (as modified by sec. 10104).
Oversight by the Office of Personnel Management. Requires the Director of OPM to enter into contracts with issuers (which may include a group of issuers affiliated either by common ownership and control or by common use of a nationally licensed service mark) without regard to the requirements under the law authorizing the FEHBP or other
statutes requiring competitive bidding, to offer at least 2 multi-state QHPs through each Exchange in each state. Requires these plans to provide individual, or in the case of small employers, group coverage. Requires contracts to be at least for 1 year,
automatically renewable in the absence of notice of termination by either party. Requires the coverage to be in accordance with the types required under the Act. Requires the Director to ensure that at least one contract is with a non-profit entity.
Requires the Director to implement this provision in a manner similar to the manner in which he or she implements the contracting under FEHBP including (through negotiation with each multi-state plan): 1) a medical loss ratio; 2) profit margin; 3) premiums; 4) such other terms and conditions of coverage as are in the interests of enrollees in such plans. Permits the Director to prohibit the offering of a multi-state plan that does not meet the terms and conditions with respect to consumer protections. Requires the Director to ensure that with respect to multi-state QHPs offered in an Exchange, there is at least one that does not provide coverage of elective abortions. Permits the Director to withdraw a contract only after notice and opportunity for hearing.
Eligibility. To be eligible, an issuer must agree to offer a multi-state QHP meeting requirements in each Exchange in each state; is licensed in each state and is subject to all requirements of state law not inconsistent with this section, including the standards and requirements that a state imposes that do not prevent the application of the Act’s insurance reforms; otherwise complies with minimum standards prescribed for carriers under FEHBP to the extent they do not conflict with this Act; and meets other
requirements as determined appropriate by the Director, in consultation with the Secretary.
Requirements. Provides that a plan meets the requirements if, in the determination of the Director, it offers a benefits package that is uniform in each state and consists of the essential benefits package; meets requirements relating to the offering of the bronze, silver and gold levels of coverage and catastrophic coverage in each state Exchange; the issuer rates its premiums on the basis of the rating requirements of the bill; and the issuer offers the plan in all geographic regions and in all states that have adopted adjusted community rating before the date of enactment. Permits states to require that benefits in addition to the essential benefits be provided to enrollees of a multi-state QHP offered in that state but only if the state defrays any additional cost for premium credits resulting from the additional benefits.
Application of certain state rating requirements. Provides that in the case of a multi-state QHP offered in a state with age rating lower than 3:1, the state may require that
Exchanges operating in that state only permit the offering of multi-state plans that comply with those more protective age rating requirements.
Credits. Provides that an individual enrolled in a multi-state QHP is eligible for premium credits and cost sharing assistance in the same manner as an individual enrolled in a QHP.
Plans deemed to be certified. Deems a multi-state QHP as certified by an Exchange.
Phase-in. Notwithstanding the requirements above related to offering in all states and being licensed in all states, requires the Director to contract with an issuer for the
offering of a multi-state QHP if: 1) with respect to the first year for which the issuer offers the plan, the issuer offers it in at least 60% of the states; 2) for the second year, at least 70% of the states; 3) for the third year, at least 85%; and for each subsequent year, in all states.
Applicability. Applies the FEHBP requirements to multi-state QHPs to the extent that the requirements do not conflict with a provision of this title.
Continued support for FEHBP. Clarifies that OPM must maintain effort with respect to the administration of FEHBP. Provides for a separate risk pool apart from the enrollees in FEHBP. Permits the Director to establish separate units or offices within OPM and to appoint additional personnel to ensure that the administration of multi-state QHPs does not interfere with effective administration of FEHBP. Clarifies that carriers participating in FEHBP are not required to also offer a multi-state QHP. Premiums paid for multi-state QHPs are not considered Federal funds for any purpose.
Advisory board. Requires the Director to establish an advisory board to provide
recommendations on the activities described above. Requires a significant percentage of the members of the board to be comprised of enrollees in multi-state QHP or
representatives of such enrollees.
Authorization of appropriations. Authorizes to be appropriated such sums as may be necessary to carry out this section.
Effective 3/23/2010.