§ 18023. Special rules

2,367 words·~11 min read·/usc/title-42/section-18023

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(a)State opt-out of abortion coverage

(1)In general A State may elect to prohibit abortion coverage in qualified health plans offered through an Exchange in such State if such State enacts a law to provide for such prohibition.

(2)Termination of opt out A State may repeal a law described in paragraph

(1)and provide for the offering of such services through the Exchange.

(b)Special rules relating to coverage of abortion services

(1)Voluntary choice of coverage of abortion services

(A)In general Notwithstanding any other provision of this title 1 (or any amendment made by this title)— 1

(i)nothing in this title 1 (or any amendment made by this title),1 shall be construed to require a qualified health plan to provide coverage of services described in subparagraph (B)(i) or (B)(ii) as part of its essential health benefits for any plan year; and

(ii)subject to subsection (a), the issuer of a qualified health plan shall determine whether or not the plan provides coverage of services described in subparagraph (B)(i) or (B)(ii) as part of such benefits for the plan year.

(B)Abortion services

(i)Abortions for which public funding is prohibited The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.

(ii)Abortions for which public funding is allowed The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved.

(2)Prohibition on the use of Federal funds

(A)In general If a qualified health plan provides coverage of services described in paragraph (1)(B)(i), the issuer of the plan shall not use any amount attributable to any of the following for purposes of paying for such services:

(i)The credit under section 36B of title 26 (and the amount (if any) of the advance payment of the credit under section 18082 of this title).

(ii)Any cost-sharing reduction under section 18071 of this title (and the amount (if any) of the advance payment of the reduction under section 18082 of this title).

(B)Establishment of allocation accounts In the case of a plan to which subparagraph

(A)applies, the issuer of the plan shall—

(i)collect from each enrollee in the plan (without regard to the enrollee’s age, sex, or family status) a separate payment for each of the following:

(I)an amount equal to the portion of the premium to be paid directly by the enrollee for coverage under the plan of services other than services described in paragraph (1)(B)(i) (after reduction for credits and cost-sharing reductions described in subparagraph (A)); and

(II)an amount equal to the actuarial value of the coverage of services described in paragraph (1)(B)(i), and

(ii)shall 2 deposit all such separate payments into separate allocation accounts as provided in subparagraph (C).

In the case of an enrollee whose premium for coverage under the plan is paid through employee payroll deposit, the separate payments required under this subparagraph shall each be paid by a separate deposit.

(C)Segregation of funds

(i)In general The issuer of a plan to which subparagraph

(A)applies shall establish allocation accounts described in clause

(ii)for enrollees receiving amounts described in subparagraph (A).

(ii)Allocation accounts The issuer of a plan to which subparagraph

(A)applies shall deposit—

(I)all payments described in subparagraph (B)(i)(I) into a separate account that consists solely of such payments and that is used exclusively to pay for services other than services described in paragraph (1)(B)(i); and

(II)all payments described in subparagraph (B)(i)(II) into a separate account that consists solely of such payments and that is used exclusively to pay for services described in paragraph (1)(B)(i).

(D)Actuarial value

(i)In general The issuer of a qualified health plan shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under the qualified health plan of the services described in paragraph (1)(B)(i).

(ii)Considerations In making such estimate, the issuer—

(I)may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care;

(II)shall estimate such costs as if such coverage were included for the entire population covered; and

(III)may not estimate such a cost at less than $1 per enrollee, per month.

(E)Ensuring compliance with segregation requirements

(i)In general Subject to clause (ii), State health insurance commissioners shall ensure that health plans comply with the segregation requirements in this subsection through the segregation of plan funds in accordance with applicable provisions of generally accepted accounting requirements, circulars on funds management of the Office of Management and Budget, and guidance on accounting of the Government Accountability Office.

(ii)Clarification Nothing in clause

(i)shall prohibit the right of an individual or health plan to appeal such action in courts of competent jurisdiction.

(3)Rules relating to notice

(A)Notice A qualified health plan that provides for coverage of the services described in paragraph (1)(B)(i) shall provide a notice to enrollees, only as part of the summary of benefits and coverage explanation, at the time of enrollment, of such coverage.

(B)Rules relating to payments The notice described in subparagraph (A), any advertising used by the issuer with respect to the plan, any information provided by the Exchange, and any other information specified by the Secretary shall provide information only with respect to the total amount of the combined payments for services described in paragraph (1)(B)(i) and other services covered by the plan.

(4)No discrimination on basis of provision of abortion No qualified health plan offered through an Exchange may discriminate against any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions 3

(c)Application of State and Federal laws regarding abortion

(1)No preemption of State laws regarding abortion Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.

(2)No effect on Federal laws regarding abortion

(A)44 So in original. There is no subpar. (B). In general Nothing in this Act shall be construed to have any effect on Federal laws regarding—

(i)conscience protection;

(ii)willingness or refusal to provide abortion; and

(iii)discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.

(3)No effect on Federal civil rights law Nothing in this subsection shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964 [42 U.S.C. 2000e et seq.].

(d)Application of emergency services laws Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1395dd of this title (popularly known as “EMTALA”).

(Pub. L. 111–148, title I, § 1303, title X, § 10104(c), Mar. 23, 2010, 124 Stat. 168, 896.)

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