42 USC 18071 - Reduced cost-sharing for individuals enrolling in qualified health plans

U.S Code last checked for updates: Nov 22, 2024

§ 18071.

Reduced cost-sharing for individuals enrolling in qualified health plans

(a)

In general

In the case of an eligible insured enrolled in a qualified health plan—

(1)

the Secretary shall notify the issuer of the plan of such eligibility; and

(2)

the issuer shall reduce the cost-sharing under the plan at the level and in the manner specified in subsection (c).

(b)

Eligible insured

In this section, the term “eligible insured” means an individual—

(1)

who enrolls in a qualified health plan in the silver level of coverage in the individual market offered through an Exchange; and

(2)

whose household income exceeds 100 percent but does not exceed 400 percent of the poverty line for a family of the size involved.

In the case of an individual described in section 36B(c)(1)(B) of title 26, the individual shall be treated as having household income equal to 100 percent for purposes of applying this section.

(c)

Determination of reduction in cost-sharing

(1)

Reduction in out-of-pocket limit

(A)

In general

The reduction in cost-sharing under this subsection shall first be achieved by reducing the applicable out-of pocket 1

 So in original. Probably should be “out-of-pocket”.

limit under section 18022(c)(1) of this title in the case of—

(i)

an eligible insured whose household income is more than 100 percent but not more than 200 percent of the poverty line for a family of the size involved, by two-thirds;

(ii)

an eligible insured whose household income is more than 200 percent but not more than 300 percent of the poverty line for a family of the size involved, by one-half; and

(iii)

an eligible insured whose household income is more than 300 percent but not more than 400 percent of the poverty line for a family of the size involved, by one-third.

(B)

Coordination with actuarial value limits

(i)

In general

The Secretary shall ensure the reduction under this paragraph shall not result in an increase in the plan’s share of the total allowed costs of benefits provided under the plan above—

(I)

94 percent in the case of an eligible insured described in paragraph (2)(A);

(II)

87 percent in the case of an eligible insured described in paragraph (2)(B);

(III)

73 percent in the case of an eligible insured whose household income is more than 200 percent but not more than 250 percent of the poverty line for a family of the size involved; and

(IV)

70 percent in the case of an eligible insured whose household income is more than 250 percent but not more than 400 percent of the poverty line for a family of the size involved.

(ii)

Adjustment

(2)

Additional reduction for lower income insureds

The Secretary shall establish procedures under which the issuer of a qualified health plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to—

(A)

in the case of an eligible insured whose household income is not less than 100 percent but not more than 150 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 94 percent of such costs;

(B)

in the case of an eligible insured whose household income is more than 150 percent but not more than 200 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 87 percent of such costs; and

(C)

in the case of an eligible insured whose household income is more than 200 percent but not more than 250 percent of the poverty line for a family of the size involved, increase the plan’s share of the total allowed costs of benefits provided under the plan to 73 percent of such costs.

(3)

Methods for reducing cost-sharing

(A)

In general

(B)

Capitated payments

(4)

Additional benefits

(5)

Special rule for pediatric dental plans

(d)

Special rules for Indians

(1)

Indians under 300 percent of poverty

If an individual enrolled in any qualified health plan in the individual market through an Exchange is an Indian (as defined in section 5304(d) of title 25) whose household income is not more than 300 percent of the poverty line for a family of the size involved, then, for purposes of this section—

(A)

such individual shall be treated as an eligible insured; and

(B)

the issuer of the plan shall eliminate any cost-sharing under the plan.

(2)

Items or services furnished through Indian health providers

If an Indian (as so defined) enrolled in a qualified health plan is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services—

(A)

no cost-sharing under the plan shall be imposed under the plan for such item or service; and

(B)

the issuer of the plan shall not reduce the payment to any such entity for such item or service by the amount of any cost-sharing that would be due from the Indian but for subparagraph (A).

(3)

Payment

(e)

Rules for individuals not lawfully present

(1)

In general

If an individual who is an eligible insured is not lawfully present—

(A)

no cost-sharing reduction under this section shall apply with respect to the individual; and

(B)

for purposes of applying this section, the determination as to what percentage a taxpayer’s household income bears to the poverty level for a family of the size involved shall be made under one of the following methods:

(i)

A method under which—

(I)

the taxpayer’s family size is determined by not taking such individuals into account, and

(II)

the taxpayer’s household income is equal to the product of the taxpayer’s household income (determined without regard to this subsection) and a fraction—

(aa)

the numerator of which is the poverty line for the taxpayer’s family size determined after application of subclause (I), and

(bb)

the denominator of which is the poverty line for the taxpayer’s family size determined without regard to subclause (I).

(ii)

A comparable method reaching the same result as the method under clause (i).

(2)

Lawfully present

(3)

Secretarial authority

(f)

Special rule for individuals who receive unemployment compensation during 2021

For purposes of this section, in the case of an individual who has received, or has been approved to receive, unemployment compensation for any week beginning during 2021, for the plan year in which such week begins—

(1)

such individual shall be treated as meeting the requirements of subsection (b)(2), and

(2)

for purposes of subsections (c) and (d), there shall not be taken into account any household income of the individual in excess of 133 percent of the poverty line for a family of the size involved.

(g)

Definitions and special rules

In this section:

(1)

In general

(2)

Limitations on reduction

(3)

Data used for eligibility

(Pub. L. 111–148, title I, § 1402, Mar. 23, 2010, 124 Stat. 220; Pub. L. 111–152, title I, § 1001(b), Mar. 30, 2010, 124 Stat. 1031; Pub. L. 117–2, title II, § 2305(a), Mar. 11, 2021, 135 Stat. 39.)

cite as: 42 USC 18071