Sec. 6. Individual Market Reinsurance Fund

1,042 words·~5 min read·/bill/116/hr/1346/ih/section-6

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

There is established the Individual Market Reinsurance Fund (in this section referred to as the Fund ) to be administered by the Secretary to provide funding for an individual market stabilization reinsurance program in each State that complies with the requirements of this section. Amounts made available to the Fund shall consist of the funds deposited into the Fund under paragraph

(3)and shall be used to carry out this section (other than subsection (c)) for each calendar year beginning with 2021. Amounts made available to the Fund shall remain available without fiscal or calendar year limitation to carry out this section. A qualified health plan that participates in the reinsurance program established under subsection

(b)shall pay the fee established under subparagraph (B). The Secretary is authorized to charge a fee to each qualified health plan that participates in the reinsurance program established under subsection (b). Any amounts collected pursuant to this paragraph shall be deposited into the Fund for purposes of payments under subsection (b). In establishing the fee under subparagraph (B)— the Secretary shall consult with interested parties; and shall ensure that the amount of such fee is not excessive so as to unduly discourage qualified health plans from participating in the reinsurance program. The Secretary shall use amounts in the Fund to establish a reinsurance program under which the Secretary shall make reinsurance payments, subject to subsection (a)(3), to health insurance issuers with respect to high-cost individuals enrolled in qualified health plans offered by such issuers that are not grandfathered health plans or transitional health plans for any plan year beginning with the 2018 plan year. This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide payments from the Fund in accordance with this subsection. The payment made to a health insurance issuer under paragraph

(1)with respect to each high-cost individual enrolled in a qualified health plan issued by the issuer that is not a grandfathered health plan or a transitional health plan shall equal 80 percent of the lesser of— the amount (if any) by which the individual’s claims incurred during the plan year exceeds— in the case of the 2019, 2020, or 2021 plan year, $50,000; and in the case of any other plan year, $100,000; or for plan years described in— subparagraph (A)(i), $450,000; and subparagraph (A)(ii), $400,000. In the case of plan years beginning after 2019, the dollar amounts that appear in subparagraphs

(A)and

(B)of paragraph

(2)shall each be increased by an amount equal to— such amount; multiplied by the premium adjustment percentage specified under section 1302(c)(4) of the Affordable Care Act, but determined by substituting 2019 for 2013 . Payments under this subsection shall be based on such a method as the Secretary determines. The Secretary may establish a payment method by which interim payments of amounts under this subsection are made during a plan year based on the Secretary's best estimate of amounts that will be payable after obtaining all of the information. Payments under this subsection to a health insurance issuer are conditioned upon the furnishing to the Secretary, in a form and manner specified by the Secretary, of such information as may be required to carry out this subsection. Information disclosed or obtained pursuant to clause

(i)is subject to the HIPAA privacy and security law, as defined in section 3009(a) of the Public Health Service Act ( 42 U.S.C. 300jj–19(a) ). If the Secretary determines appropriate, the Secretary may substitute higher dollar amounts for the dollar amounts specified under subparagraphs

(A)and

(B)of paragraph

(2)(and adjusted under paragraph (3), if applicable) if the Secretary certifies that such substitutions, considered together, neither increase nor decease the total projected payments under this subsection. The Secretary shall submit a report to Congress, not later than January 21, 2019, and each year thereafter, that contains the following information for the most recently ended year: The number and types of plans in each State's individual market, specifying the number that are qualified health plans, grandfathered health plans, or health insurance coverage that is not a qualified health plan. The impact of the reinsurance payments provided under this section on the availability of coverage, cost of coverage, and coverage options in each State. The amount of premiums paid by individuals in each State by age, family size, geographic area in the State's individual market, and category of health plan (as described in subparagraph (A)). The process used to award funds for outreach and enrollment activities awarded to eligible entities under subsection (c), the amount of such funds awarded, and the activities carried out with such funds. Such other information as the Secretary deems relevant. Not later than January 31, 2022, the Secretary shall submit to Congress a report that— analyzes the impact of the funds provided under this section on premiums and enrollment in the individual market in all States; and contains a State-by-State comparison of the design of the programs carried out by States with funds provided under this section. In this section: The term Secretary means the Secretary of the Department of Health and Human Services. The term Fund means the Individual Market Reinsurance Fund established under subsection (a). The term grandfathered health plan has the meaning given that term in section 1251(e) of the Patient Protection and Affordable Care Act. The term high-cost individual means an individual enrolled in a qualified health plan (other than a grandfathered health plan or a transitional health plan) who incurs claims in excess of $50,000 during a plan year. The term State means each of the 50 States and the District of Columbia. The term transitional health plan means a plan continued under the letter issued by the Centers for Medicare & Medicaid Services on November 14, 2013, to the State Insurance Commissioners outlining a transitional policy for coverage in the individual and small group markets to which section 1251 of the Patient Protection and Affordable Care Act does not apply, and under the extension of the transitional policy for such coverage set forth in the Insurance Standards Bulletin Series guidance issued by the Centers for Medicare & Medicaid Services on March 5, 2014, February 29, 2016, and February 13, 2017.

Connections1 off-index

1 reference not yet in our index

42 USC 300jj–19(a)

Citation graph

cites case law

Sec. 6

Individual Market Reinsurance Fund

Cite42 USC 300jj–19(a)

Cites 1Cited by 0 across 0 sources