Sec. 101. Establish universal access programs to improve high risk pools and reinsurance markets
952 words·~4 min read·
/bill/113/hr/3165/ih/section-101A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Not later than 90 days after the date of the enactment of this Act, each State shall— subject to paragraph (3), operate a qualifying State high risk pool described in subsection (b)(1); and subject to paragraph (3), apply to the operation of such a program from State funds an amount equivalent to the portion of State funds derived from State premium assessments (as defined by the Secretary) that are not otherwise used on State health care programs. In the case of a State that is not operating a current section 2745 qualified high risk pool as of the date of the enactment of this Act, the State’s operation of a qualifying State high risk pool described in subsection (b)(1) shall be treated, for purposes of section 2745 of the Public Health Service Act, as the operation of a qualified high risk pool described in such section.
In the case of a State that is operating a current section 2745 qualified high risk pool as of the date of the enactment of this Act, as of the date that is 90 days after the date of the enactment of this Act, such a pool shall not be treated as a qualified high risk pool under section 2745 of the Public Health Service Act unless the pool is a qualifying State high risk pool described in subsection (b)(1). If the pool operated under paragraph (1)(A) is in strong fiscal health, as determined in accordance with standards established by the National Association of Insurance Commissioners and as approved by the State Insurance Commissioner involved, the requirement of paragraph (1)(B) shall be deemed to be met.
A qualifying State high risk pool described in this subsection means a current section 2745 qualified high risk pool that meets the following requirements: The pool must be funded with a stable funding source. The pool must eliminate any waiting lists so that all eligible residents who are seeking coverage through the pool should be allowed to receive coverage through the pool. The pool must allow for coverage of individuals who, but for the 24-month disability waiting period under section 226(b) of the Social Security Act, would be eligible for Medicare during the period of such waiting period.
The pool must limit the pool premiums to no more than 150 percent of the average premium for applicable standard risk rates in that State. The pool must conduct education and outreach initiatives so that residents and brokers understand that the pool is available to eligible residents. The pool must provide coverage for preventive services and disease management for chronic diseases. Subject to subparagraph (C), an individual may only be eligible for coverage through the pool if the individual has a pre-existing condition, as determined in a manner consistent with guidance ussed by the Secretary of Health and Human Services and— was denied health insurance coverage in the individual market because of a pre-existing condition or health status; or was offered such coverage— under terms that limit the coverage for such a pre-existing condition; or at a premium rate that is above the premium rate for coverage through the pool pursuant to this section.
No pre-existing condition exclusion period may be imposed on coverage through the pool. The pool shall not require an individual to be uninsured for any period as a condition of eligibility to receive coverage through the pool. Notwithstanding any other provision of law, only citizens and nationals of the United States shall be eligible to participate in a qualifying State high risk pool that receives funds under section 2745 of the Public Health Service Act or this section. As a condition of a State receiving such funds, the Secretary shall require the State to certify, to the satisfaction of the Secretary, that such State requires all applicants for coverage in the qualifying State high risk pool to provide satisfactory documentation of citizenship or nationality in a manner consistent with section 1903(x) of the Social Security Act.
The Secretary shall keep sufficient records such that a determination of citizenship or nationality only has to be made once for any individual under this paragraph. As of January 1, 2012, a pool shall not qualify as qualified high risk pool under section 2745 of the Public Health Service Act unless the pool is a qualifying State high risk pool described in paragraph (1). In order to accommodate new and innovative programs, the Secretary may waive such requirements of this section for qualifying State high risk pools as the Secretary deems appropriate.
In addition to any other amounts appropriated, there is appropriated to carry out section 2745 of the Public Health Service Act (including through a pool described in subsection (a)(1))— $15,000,000,000 for the period of fiscal years 2011 through 2021; and an additional $10,000,000,000 for the period of fiscal years 2017 through 2021. In this section: The terms health insurance coverage and health insurance issuer have the meanings given such terms in section 2791 of the Public Health Service Act.
The term current section 2745 qualified high risk pool has the meaning given the term qualified high risk pool under section 2745(g) of the Public Health Service Act as in effect as of the date of the enactment of this Act. The term Secretary means Secretary of Health and Human Services. The term standard risk rate means a rate that— is determined under the State high risk pool by considering the premium rates charged by other health insurance issuers offering health insurance coverage to individuals in the insurance market served; is established using reasonable actuarial techniques; and reflects anticipated claims experience and expenses for the coverage involved.
The term State means any of the 50 States or the District of Columbia.