42 U.S.C. § 18021 | Qualified health plan defined

(a)

Qualified health plan

1 See References in Text note below.

In this title: 

(1)

In general

The term “qualified health plan” means a health plan that—

(A)

section 18031(c) of this title 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 issued or recognized by each Exchange through which such plan is offered;

(B)

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

(C)

is offered by a health insurance issuer that—

(i)

¹ 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; 

(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)

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

(2)

Inclusion of CO–OP plans and multi-State qualified health plans

¹section 18042 of this title section 18054 of this titleAny 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 , and a multi-State plan under , unless specifically provided for otherwise.

(3)

Treatment of qualified direct primary care medical home plans

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)

Variation based on rating area

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

(b)

Terms relating to health plans

¹In this title: 

(1)

Health plan

(A)

In general

The term “health plan” means health insurance coverage and a group health plan.

(B)

Exception for self-insured plans and MEWAs

¹section 1144 of title 29Except to the extent specifically provided by this title, 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 .

(2)

Health insurance coverage and issuer

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

(3)

Group health plan

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

Pub. L. 111–148, title I, § 1301Mar. 23, 2010124 Stat. 162(, title X, § 10104(a), , , 896.)

Editorial Notes

References in Text

Pub. L. 111–148Mar. 23, 2010124 Stat. 130This title, where footnoted in text, is title I of , , , 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

Pub. L. 111–148, § 10104(a)section 18042 of this title section 18043 of this title2010—Subsec. (a)(2) to (4). , 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 or a community health insurance option under , unless specifically provided for otherwise.”