42 U.S.C. § 18031 — Affordable choices of health benefit

Page 9103 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 (3) State option to extend definition of small employer Notwithstanding paragraphs (1) and (2), nothing in this section shall prevent a State from applying this subsection by treating as a small employer, with respect to a calendar year and a plan year, an employer who em- ployed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. (4) Rules for determining employer size For purposes of this subsection— (A) Application of aggregation rule for em- ployers All persons treated as a single employer under subsection (b), (c), (m), or (o) of sec- tion 414 of title 26 shall be treated as 1 em- ployer. (B) Employers not in existence in preceding year In the case of an employer which was not in existence throughout the preceding cal- endar year, the determination of whether such employer is a small or large employer shall be based on the average number of em- ployees that it is reasonably expected such employer will employ on business days in the current calendar year. (C) Predecessors Any reference in this subsection to an em- ployer shall include a reference to any pred- ecessor of such employer. (D) Continuation of participation for grow- ing small employers If— (i) a qualified employer that is a small employer makes enrollment in qualified health plans offered in the small group market available to its employees through an Exchange; and (ii) the employer ceases to be a small employer by reason of an increase in the number of employees of such employer; the employer shall continue to be treated as a small employer for purposes of this sub- chapter for the period beginning with the in- crease and ending with the first day on which the employer does not make such en- rollment available to its employees. (c) Secretary In this title,1 the term ‘‘Secretary’’ means the Secretary of Health and Human Services. (d) State In this title,1 the term ‘‘State’’ means each of the 50 States and the District of Columbia. (e) Educated health care consumers The term ‘‘educated health care consumer’’ means an individual who is knowledgeable about the health care system, and has background or experience in making informed decisions regard- ing health, medical, and scientific matters. (Pub. L. 111–148, title I, § 1304, title X, § 10104(d), Mar. 23, 2010, 124 Stat. 171, 900; Pub. L. 114–60, § 2(a), Oct. 7, 2015, 129 Stat. 543.) Editorial Notes REFERENCES IN TEXT This title, referred to in subsecs. (a) to (d), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, which en- acted this chapter and enacted, amended, and trans- ferred numerous other sections and notes in the Code. For complete classification of title I to the Code, see Tables. AMENDMENTS 2015—Subsec. (b)(1). Pub. L. 114–60, § 2(a)(1), sub- stituted ‘‘51’’ for ‘‘101’’. Subsec. (b)(2). Pub. L. 114–60, § 2(a)(2), substituted ‘‘50’’ for ‘‘100’’. Subsec. (b)(3). Pub. L. 114–60, § 2(a)(3), amended par. (3) generally. Prior to amendment, text read as follows: ‘‘In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by sub- stituting ‘51 employees’ for ‘101 employees’ in para- graph (1) and by substituting ‘50 employees’ for ‘100 em- ployees’ in paragraph (2).’’ 2010—Subsec. (e). Pub. L. 111–148, § 10104(d), added sub- sec. (e). PART B—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH BENEFIT EX- CHANGES § 18031. Affordable choices of health benefit plans (a) Assistance to States to establish American Health Benefit Exchanges (1) Planning and establishment grants There shall be appropriated to the Sec- retary, out of any moneys in the Treasury not otherwise appropriated, an amount necessary to enable the Secretary to make awards, not later than 1 year after March 23, 2010, to States in the amount specified in paragraph (2) for the uses described in paragraph (3). (2) Amount specified For each fiscal year, the Secretary shall de- termine the total amount that the Secretary will make available to each State for grants under this subsection. (3) Use of funds A State shall use amounts awarded under this subsection for activities (including plan- ning activities) related to establishing an American Health Benefit Exchange, as de- scribed in subsection (b). (4) Renewability of grant (A) In general Subject to subsection (d)(4), the Secretary may renew a grant awarded under paragraph (1) if the State recipient of such grant— (i) is making progress, as determined by the Secretary, toward— (I) establishing an Exchange; and (II) implementing the reforms de- scribed in subtitles A and C (and the amendments made by such subtitles); and (ii) is meeting such other benchmarks as the Secretary may establish. (B) Limitation No grant shall be awarded under this sub- section after January 1, 2015. Page 9104 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 1 See References in Text note below. (5) Technical assistance to facilitate participa- tion in SHOP Exchanges The Secretary shall provide technical assist- ance to States to facilitate the participation of qualified small businesses in such States in SHOP Exchanges. (b) American Health Benefit Exchanges (1) In general Each State shall, not later than January 1, 2014, establish an American Health Benefit Ex- change (referred to in this title 1 as an ‘‘Ex- change’’) for the State that— (A) facilitates the purchase of qualified health plans; (B) provides for the establishment of a Small Business Health Options Program (in this title 1 referred to as a ‘‘SHOP Ex- change’’) that is designed to assist qualified employers in the State who are small em- ployers in facilitating the enrollment of their employees in qualified health plans of- fered in the small group market in the State; and (C) meets the requirements of subsection (d). (2) Merger of individual and SHOP Exchanges A State may elect to provide only one Ex- change in the State for providing both Ex- change and SHOP Exchange services to both qualified individuals and qualified small em- ployers, but only if the Exchange has adequate resources to assist such individuals and em- ployers. (c) Responsibilities of the Secretary (1) In general The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified health plans. Such criteria shall re- quire that, to be certified, a plan shall, at a minimum— (A) meet marketing requirements, and not employ marketing practices or benefit de- signs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs; (B) ensure a sufficient choice of providers (in a manner consistent with applicable net- work adequacy provisions under section 2702(c) of the Public Health Service Act [42 U.S.C. 300gg–1(c)]), and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-net- work providers; (C) include within health insurance plan networks those essential community pro- viders, where available, that serve predomi- nately low-income, medically-underserved individuals, such as health care providers de- fined in section 340B(a)(4) of the Public Health Service Act [42 U.S.C. 256b(a)(4)] and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act [42 U.S.C. 1396r–8(c)(1)(D)(i)(IV)] as set forth by section 221 of Public Law 111–8, except that nothing in this subparagraph shall be construed to require any health plan to pro- vide coverage for any specific medical proce- dure; (D)(i) be accredited with respect to local performance on clinical quality measures such as the Healthcare Effectiveness Data and Information Set, patient experience rat- ings on a standardized Consumer Assessment of Healthcare Providers and Systems survey, as well as consumer access, utilization man- agement, quality assurance, provider credentialing, complaints and appeals, net- work adequacy and access, and patient infor- mation programs by any entity recognized by the Secretary for the accreditation of health insurance issuers or plans (so long as any such entity has transparent and rig- orous methodological and scoring criteria); or (ii) receive such accreditation within a pe- riod established by an Exchange for such ac- creditation that is applicable to all qualified health plans; (E) implement a quality improvement strategy described in subsection (g)(1); (F) utilize a uniform enrollment form that qualified individuals and qualified employers may use (either electronically or on paper) in enrolling in qualified health plans offered through such Exchange, and that takes into account criteria that the National Associa- tion of Insurance Commissioners develops and submits to the Secretary; (G) utilize the standard format established for presenting health benefits plan options; (H) provide information to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, on any quality measures for health plan performance en- dorsed under section 399JJ of the Public Health Service Act [42 U.S.C. 280j–2], as ap- plicable; and (I) report to the Secretary at least annu- ally and in such manner as the Secretary shall require, pediatric quality reporting measures consistent with the pediatric qual- ity reporting measures established under section 1139A of the Social Security Act [42 U.S.C. 1320b–9a]. (2) Rule of construction Nothing in paragraph (1)(C) shall be con- strued to require a qualified health plan to contract with a provider described in such paragraph if such provider refuses to accept the generally applicable payment rates of such plan. (3) Rating system The Secretary shall develop a rating system that would rate qualified health plans offered through an Exchange in each benefits level on the basis of the relative quality and price. The Exchange shall include the quality rating in the information provided to individuals and employers through the Internet portal estab- lished under paragraph (4). (4) Enrollee satisfaction system The Secretary shall develop an enrollee sat- isfaction survey system that would evaluate the level of enrollee satisfaction with qualified health plans offered through an Exchange, for Page 9105 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 each such qualified health plan that had more than 500 enrollees in the previous year. The Exchange shall include enrollee satisfaction information in the information provided to in- dividuals and employers through the Internet portal established under paragraph (5) in a manner that allows individuals to easily com- pare enrollee satisfaction levels between com- parable plans. (5) Internet portals The Secretary shall— (A) continue to operate, maintain, and up- date the Internet portal developed under sec- tion 18003(a) of this title and to assist States in developing and maintaining their own such portal; and (B) make available for use by Exchanges a model template for an Internet portal that may be used to direct qualified individuals and qualified employers to qualified health plans, to assist such individuals and employ- ers in determining whether they are eligible to participate in an Exchange or eligible for a premium tax credit or cost-sharing reduc- tion, and to present standardized informa- tion (including quality ratings) regarding qualified health plans offered through an Ex- change to assist consumers in making easy health insurance choices. Such template shall include, with respect to each qualified health plan offered through the Exchange in each rating area, access to the uniform outline of coverage the plan is re- quired to provide under section 2716 1 of the Public Health Service Act and to a copy of the plan’s written policy. (6) Enrollment periods The Secretary shall require an Exchange to provide for— (A) an initial open enrollment, as deter- mined by the Secretary (such determination to be made not later than July 1, 2012); (B) annual open enrollment periods, as de- termined by the Secretary for calendar years after the initial enrollment period; (C) special enrollment periods specified in section 9801 of title 26 and other special en- rollment periods under circumstances simi- lar to such periods under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.]; and (D) special monthly enrollment periods for Indians (as defined in section 1603 of title 25). (7) Reenrollment of certain individuals in qualified health plans in certain exchanges (A) In general In the case of an Exchange that the Sec- retary operates pursuant to section 18041(c)(1) of this title, the Secretary shall establish a process under which an indi- vidual described in subparagraph (B) is re- enrolled for plan year 2021 in a qualified health plan offered through such Exchange. Such qualified health plan under which such individual is so reenrolled shall be— (i) if available for plan year 2021, the qualified health plan under which such in- dividual is enrolled during the annual open enrollment period for such plan year; and (ii) if such qualified health plan is not available for plan year 2021, a qualified health plan offered through such Exchange determined appropriate by the Secretary. (B) Individual described An individual described in this subsection is an individual who, with respect to plan year 2020— (i) resides in a State with an Exchange described in subparagraph (A); (ii) is enrolled in a qualified health plan during such plan year and does not enroll in a qualified health plan for plan year 2021 during the annual open enrollment period for such plan year 2021; and (iii) does not elect to disenroll under a qualified health plan for plan year 2021 during such annual open enrollment pe- riod. (d) Requirements (1) In general An Exchange shall be a governmental agen- cy or nonprofit entity that is established by a State. (2) Offering of coverage (A) In general An Exchange shall make available quali- fied health plans to qualified individuals and qualified employers. (B) Limitation (i) In general An Exchange may not make available any health plan that is not a qualified health plan. (ii) Offering of stand-alone dental benefits Each Exchange within a State shall allow an issuer of a plan that only provides limited scope dental benefits meeting the requirements of section 9832(c)(2)(A) of title 26 to offer the plan through the Ex- change (either separately or in conjunc- tion with a qualified health plan) if the plan provides pediatric dental benefits meeting the requirements of section 18022(b)(1)(J) of this title). (3) Rules relating to additional required bene- fits (A) In general Except as provided in subparagraph (B), an Exchange may make available a qualified health plan notwithstanding any provision of law that may require benefits other than the essential health benefits specified under section 18022(b) of this title. (B) States may require additional benefits (i) In general Subject to the requirements of clause (ii), a State may require that a qualified health plan offered in such State offer ben- efits in addition to the essential health benefits specified under section 18022(b) of this title. (ii) State must assume cost A State shall make payments— Page 9106 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 (I) to an individual enrolled in a quali- fied health plan offered in such State; or (II) on behalf of an individual described in subclause (I) directly to the qualified health plan in which such individual is enrolled; to defray the cost of any additional bene- fits described in clause (i). (4) Functions An Exchange shall, at a minimum— (A) implement procedures for the certifi- cation, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (c), of health plans as qualified health plans; (B) provide for the operation of a toll-free telephone hotline to respond to requests for assistance; (C) maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may obtain standard- ized comparative information on such plans; (D) assign a rating to each qualified health plan offered through such Exchange in ac- cordance with the criteria developed by the Secretary under subsection (c)(3); (E) utilize a standardized format for pre- senting health benefits plan options in the Exchange, including the use of the uniform outline of coverage established under section 2715 of the Public Health Service Act [42 U.S.C. 300gg–15]; (F) in accordance with section 18083 of this title, inform individuals of eligibility re- quirements for the medicaid program under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.], the CHIP program under title XXI of such Act [42 U.S.C. 1397aa et seq.], or any applicable State or local public program and if through screening of the ap- plication by the Exchange, the Exchange de- termines that such individuals are eligible for any such program, enroll such individ- uals in such program; (G) establish and make available by elec- tronic means a calculator to determine the actual cost of coverage after the application of any premium tax credit under section 36B of title 26 and any cost-sharing reduction under section 18071 of this title; (H) subject to section 18081 of this title, grant a certification attesting that, for pur- poses of the individual responsibility pen- alty under section 5000A of title 26, an indi- vidual is exempt from the individual require- ment or from the penalty imposed by such section because— (i) there is no affordable qualified health plan available through the Exchange, or the individual’s employer, covering the in- dividual; or (ii) the individual meets the require- ments for any other such exemption from the individual responsibility requirement or penalty; (I) transfer to the Secretary of the Treas- ury— (i) a list of the individuals who are issued a certification under subparagraph (H), including the name and taxpayer iden- tification number of each individual; (ii) the name and taxpayer identification number of each individual who was an em- ployee of an employer but who was deter- mined to be eligible for the premium tax credit under section 36B of title 26 be- cause— (I) the employer did not provide min- imum essential coverage; or (II) the employer provided such min- imum essential coverage but it was de- termined under section 36B(c)(2)(C) of such title to either be unaffordable to the employee or not provide the required minimum actuarial value; and (iii) the name and taxpayer identifica- tion number of each individual who noti- fies the Exchange under section 18081(b)(4) of this title that they have changed em- ployers and of each individual who ceases coverage under a qualified health plan dur- ing a plan year (and the effective date of such cessation); (J) provide to each employer the name of each employee of the employer described in subparagraph (I)(ii) who ceases coverage under a qualified health plan during a plan year (and the effective date of such ces- sation); and (K) establish the Navigator program de- scribed in subsection (i). (5) Funding limitations (A) No Federal funds for continued oper- ations In establishing an Exchange under this section, the State shall ensure that such Ex- change is self-sustaining beginning on Janu- ary 1, 2015, including allowing the Exchange to charge assessments or user fees to partici- pating health insurance issuers, or to other- wise generate funding, to support its oper- ations. (B) Prohibiting wasteful use of funds In carrying out activities under this sub- section, an Exchange shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, exces- sive executive compensation, or promotion of Federal or State legislative and regu- latory modifications. (6) Consultation An Exchange shall consult with stakeholders relevant to carrying out the activities under this section, including— (A) educated health care consumers who are enrollees in qualified health plans; (B) individuals and entities with experi- ence in facilitating enrollment in qualified health plans; (C) representatives of small businesses and self-employed individuals; (D) State Medicaid offices; and (E) advocates for enrolling hard to reach populations. (7) Publication of costs An Exchange shall publish the average costs of licensing, regulatory fees, and any other Page 9107 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 payments required by the Exchange, and the administrative costs of such Exchange, on an Internet website to educate consumers on such costs. Such information shall also include monies lost to waste, fraud, and abuse. (e) Certification (1) In general An Exchange may certify a health plan as a qualified health plan if— (A) such health plan meets the require- ments for certification as promulgated by the Secretary under subsection (c)(1); and (B) the Exchange determines that making available such health plan through such Ex- change is in the interests of qualified indi- viduals and qualified employers in the State or States in which such Exchange operates, except that the Exchange may not exclude a health plan— (i) on the basis that such plan is a fee- for-service plan; (ii) through the imposition of premium price controls; or (iii) on the basis that the plan provides treatments necessary to prevent patients’ deaths in circumstances the Exchange de- termines are inappropriate or too costly. (2) Premium considerations The Exchange shall require health plans seeking certification as qualified health plans to submit a justification for any premium in- crease prior to implementation of the in- crease. Such plans shall prominently post such information on their websites. The Exchange shall take this information, and the informa- tion and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public Health Service Act [42 U.S.C. 300gg–94(b)(1)] (relating to patterns or prac- tices of excessive or unjustified premium in- creases), into consideration when determining whether to make such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States. (3) Transparency in coverage (A) In general The Exchange shall require health plans seeking certification as qualified health plans to submit to the Exchange, the Sec- retary, the State insurance commissioner, and make available to the public, accurate and timely disclosure of the following infor- mation: (i) Claims payment policies and prac- tices. (ii) Periodic financial disclosures. (iii) Data on enrollment. (iv) Data on disenrollment. (v) Data on the number of claims that are denied. (vi) Data on rating practices. (vii) Information on cost-sharing and payments with respect to any out-of-net- work coverage. (viii) Information on enrollee and partic- ipant rights under this title.1 (ix) Other information as determined ap- propriate by the Secretary. (B) Use of plain language The information required to be submitted under subparagraph (A) shall be provided in plain language. The term ‘‘plain language’’ means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is concise, well-orga- nized, and follows other best practices of plain language writing. The Secretary and the Secretary of Labor shall jointly develop and issue guidance on best practices of plain language writing. (C) Cost sharing transparency The Exchange shall require health plans seeking certification as qualified health plans to permit individuals to learn the amount of cost-sharing (including deductibles, copayments, and coinsurance) under the individual’s plan or coverage that the individual would be responsible for pay- ing with respect to the furnishing of a spe- cific item or service by a participating pro- vider in a timely manner upon the request of the individual. At a minimum, such informa- tion shall be made available to such indi- vidual through an Internet website and such other means for individuals without access to the Internet. (D) Group health plans The Secretary of Labor shall update and harmonize the Secretary’s rules concerning the accurate and timely disclosure to par- ticipants by group health plans of plan dis- closure, plan terms and conditions, and peri- odic financial disclosure with the standards established by the Secretary under subpara- graph (A). (f) Flexibility (1) Regional or other interstate exchanges An Exchange may operate in more than one State if— (A) each State in which such Exchange op- erates permits such operation; and (B) the Secretary approves such regional or interstate Exchange. (2) Subsidiary Exchanges A State may establish one or more sub- sidiary Exchanges if— (A) each such Exchange serves a geo- graphically distinct area; and (B) the area served by each such Exchange is at least as large as a rating area described in section 2701(a) of the Public Health Serv- ice Act [42 U.S.C. 300gg(a)]. (3) Authority to contract (A) In general A State may elect to authorize an Ex- change established by the State under this section to enter into an agreement with an eligible entity to carry out 1 or more respon- sibilities of the Exchange. (B) Eligible entity In this paragraph, the term ‘‘eligible enti- ty’’ means— Page 9108 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 (i) a person— (I) incorporated under, and subject to the laws of, 1 or more States; (II) that has demonstrated experience on a State or regional basis in the indi- vidual and small group health insurance markets and in benefits coverage; and (III) that is not a health insurance issuer or that is treated under subsection (a) or (b) of section 52 of title 26 as a member of the same controlled group of corporations (or under common control with) as a health insurance issuer; or (ii) the State medicaid agency under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.]. (g) Rewarding quality through market-based in- centives (1) Strategy described A strategy described in this paragraph is a payment structure that provides increased re- imbursement or other incentives for— (A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic dis- ease management, medication and care com- pliance initiatives, including through the use of the medical home model, for treat- ment or services under the plan or coverage; (B) the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital dis- charge that includes patient-centered edu- cation and counseling, comprehensive dis- charge planning, and post discharge rein- forcement by an appropriate health care pro- fessional; (C) the implementation of activities to im- prove patient safety and reduce medical er- rors through the appropriate use of best clin- ical practices, evidence based medicine, and health information technology under the plan or coverage; (D) the implementation of wellness and health promotion activities; and (E) the implementation of activities to re- duce health and health care disparities, in- cluding through the use of language serv- ices, community outreach, and cultural competency trainings. (2) Guidelines The Secretary, in consultation with experts in health care quality and stakeholders, shall develop guidelines concerning the matters de- scribed in paragraph (1). (3) Requirements The guidelines developed under paragraph (2) shall require the periodic reporting to the ap- plicable Exchange of the activities that a qualified health plan has conducted to imple- ment a strategy described in paragraph (1). (h) Quality improvement (1) Enhancing patient safety Beginning on January 1, 2015, a qualified health plan may contract with— (A) a hospital with greater than 50 beds only if such hospital— (i) utilizes a patient safety evaluation system as described in part C of title IX of the Public Health Service Act [42 U.S.C. 299b–21 et seq.]; and (ii) implements a mechanism to ensure that each patient receives a comprehen- sive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge plan- ning, and post discharge reinforcement by an appropriate health care professional; or (B) a health care provider only if such pro- vider implements such mechanisms to im- prove health care quality as the Secretary may by regulation require. (2) Exceptions The Secretary may establish reasonable ex- ceptions to the requirements described in paragraph (1). (3) Adjustment The Secretary may by regulation adjust the number of beds described in paragraph (1)(A). (i) Navigators (1) In general An Exchange shall establish a program under which it awards grants to entities de- scribed in paragraph (2) to carry out the duties described in paragraph (3). (2) Eligibility (A) In general To be eligible to receive a grant under paragraph (1), an entity shall demonstrate to the Exchange involved that the entity has existing relationships, or could readily es- tablish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-em- ployed individuals likely to be qualified to enroll in a qualified health plan. (B) Types Entities described in subparagraph (A) may include trade, industry, and profes- sional associations, commercial fishing in- dustry organizations, ranching and farming organizations, community and consumer-fo- cused nonprofit groups, chambers of com- merce, unions, resource partners of the Small Business Administration, other li- censed insurance agents and brokers, and other entities that— (i) are capable of carrying out the duties described in paragraph (3); (ii) meet the standards described in para- graph (4); and (iii) provide information consistent with the standards developed under paragraph (5). (3) Duties An entity that serves as a navigator under a grant under this subsection shall— (A) conduct public education activities to raise awareness of the availability of quali- fied health plans; (B) distribute fair and impartial informa- tion concerning enrollment in qualified health plans, and the availability of pre- Page 9109 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18031 mium tax credits under section 36B of title 26 and cost-sharing reductions under section 18071 of this title; (C) facilitate enrollment in qualified health plans; (D) provide referrals to any applicable of- fice of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Serv- ice Act [42 U.S.C. 300gg–93], or any other ap- propriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, cov- erage, or a determination under such plan or coverage; and (E) provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges. (4) Standards (A) In general The Secretary shall establish standards for navigators under this subsection, including provisions to ensure that any private or pub- lic entity that is selected as a navigator is qualified, and licensed if appropriate, to en- gage in the navigator activities described in this subsection and to avoid conflicts of in- terest. Under such standards, a navigator shall not— (i) be a health insurance issuer; or (ii) receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or employees of a qualified employer in a qualified health plan. (5) Fair and impartial information and services The Secretary, in collaboration with States, shall develop standards to ensure that infor- mation made available by navigators is fair, accurate, and impartial. (6) Funding Grants under this subsection shall be made from the operational funds of the Exchange and not Federal funds received by the State to establish the Exchange. (j) Applicability of mental health parity Section 2726 of the Public Health Service Act [42 U.S.C. 300gg–26] shall apply to qualified health plans in the same manner and to the same extent as such section applies to health in- surance issuers and group health plans. (k) Conflict An Exchange may not establish rules that con- flict with or prevent the application of regula- tions promulgated by the Secretary under this subchapter. (Pub. L. 111–148, title I, § 1311, title X, §§ 10104(e)–(h), 10203(a), Mar. 23, 2010, 124 Stat. 173, 900, 901, 927; Pub. L. 116–94, div. N, title I, § 608, Dec. 20, 2019, 133 Stat. 3130.) Editorial Notes REFERENCES IN TEXT Subtitles A and C, referred to in subsec. (a)(4)(A)(i)(II), are subtitles A (§§ 1001–1004) and C (§§ 1201–1255), respectively, of title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, 154. Subtitle A enacted sec- tions 300gg–11 to 300gg–19, 300gg–93, and 300gg–94 of this title, transferred sections 300gg–4 to 300gg–7 and 300gg–13 of this title to sections 300gg–25 to 300gg–28 and 300gg–9 of this title, respectively, amended sections 300gg–11, 300gg–12, and 300gg–21 to 300gg–23 of this title, and enacted provisions set out as a note under section 300gg–11 of this title. Subtitle C enacted subchapter II of this chapter and sections 300gg to 300gg–2 and 300gg–4 to 300gg–7 of this title, transferred section 300gg of this title to section 300gg–3 of this title, amended sections 300gg–1 and 300gg–4 of this title, and enacted provisions set out as a note under section 300gg of this title. For complete classification of subtitles A and C to the Code, see Tables. This title, referred to in subsecs. (b)(1) and (e)(3)(A)(viii), is title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 130, 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. Section 2716 of the Public Health Service Act, re- ferred to in subsec. (c)(5), probably should be section 2715 of the Public Health Service Act, act July 1, 1944, which is classified to section 300gg–15 of this title and requires the Secretary to develop a uniform expla- nation of coverage documents and standardized defini- tions. Section 2716 of act July 1, 1944, which is classified to section 300gg–16 of this title, relates to prohibition on discrimination in favor of highly compensated indi- viduals. The Social Security Act, referred to in subsecs. (c)(6)(C), (d)(4)(F), and (f)(3)(B)(ii), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Part D of title XVIII of the Act is classified generally to part D (§ 1395w–101 et seq.) of sub- chapter XVIII of chapter 7 of this title. Titles XIX and XXI of the Act are classified generally to subchapters XIX (§ 1396 et seq.) and XXI (§ 1397aa et seq.), respec- tively, of chapter 7 of this title. For complete classi- fication of this Act to the Code, see section 1305 of this title and Tables. The Public Health Service Act, referred to in subsec. (h)(1)(A)(i), is act July 1, 1944, ch. 373, 58 Stat. 682. Part C of title IX of the Act is classified generally to part C (§ 299b–21 et seq.) of subchapter VII of chapter 6A of this title. For complete classification of this Act to the Code, see Short Title note set out under section 201 of this title and Tables. This subchapter, referred to in subsec. (k), was in the original ‘‘this subtitle’’, meaning subtitle D of title I of Pub. L. 111–148, Mar. 23, 2010, 124 Stat. 162, which en- acted this subchapter and amended sections 501, 4958, and 6033 of Title 26, Internal Revenue Code. AMENDMENTS 2019—Subsec. (c)(7). Pub. L. 116–94 added par. (7). 2010—Subsec. (c)(1)(I). Pub. L. 111–148, § 10203(a), added subpar. (I). Subsec. (d)(3)(B)(ii). Pub. L. 111–148, § 10104(e)(1), added cl. (ii) and struck out former cl. (ii). Prior to amendment, text read as follows: ‘‘A State shall make payments to or on behalf of an individual eligible for the premium tax credit under section 36B of title 26 and any cost-sharing reduction under section 18071 of this title to defray the cost to the individual of any addi- tional benefits described in clause (i) which are not eli- gible for such credit or reduction under section 36B(b)(3)(D) of title 26 and section 18071(c)(4) of this title.’’ Subsec. (d)(6)(A). Pub. L. 111–148, § 10104(e)(2), inserted ‘‘educated’’ before ‘‘health care’’. Subsec. (e)(2). Pub. L. 111–148, § 10104(f)(1), which di- rected substitution of ‘‘shall’’ for ‘‘may’’ in second sen- tence, was executed by making the substitution in third sentence before ‘‘take’’ to reflect the probable in- tent of Congress because the word ‘‘shall’’ already ap- peared in second sentence. Subsec. (e)(3). Pub. L. 111–148, § 10104(f)(2), added par. (3). Page 9110 TITLE 42—THE PUBLIC HEALTH AND WELFARE § 18032 1 See References in Text note below. Subsec. (g)(1)(E). Pub. L. 111–148, § 10104(g), added sub- par. (E). Subsec. (i)(2)(B). Pub. L. 111–148, § 10104(h), sub- stituted ‘‘resource partners of the Small Business Ad- ministration’’ for ‘‘small business development cen- ters’’. Statutory Notes and Related Subsidiaries ESTABLISHING A GRANT PROGRAM FOR EXCHANGE MODERNIZATION Pub. L. 117–2, title II, § 2801, Mar. 11, 2021, 135 Stat. 49, provided that: ‘‘(a) IN GENERAL.—Out of funds appropriated under subsection (b), the Secretary of Health and Human Services (in this subtitle [subtitle I (§ 2801) of title II of Pub. L. 117–2] referred to as the ‘Secretary’) shall award grants to each American Health Benefits Exchange es- tablished under section 1311(b) of the Patient Protec- tion and Affordable Care Act (42 U.S.C. 18031(b)) (other than an Exchange established by the Secretary under section 1321(c) of such Act (42 U.S.C. 18041(c))) that sub- mits to the Secretary an application at such time and in such manner, and containing such information, as specified by the Secretary, for purposes of enabling such Exchange to modernize or update any system, pro- gram, or technology utilized by such Exchange to en- sure such Exchange is compliant with all applicable re- quirements. ‘‘(b) FUNDING.—In addition to amounts otherwise available, there is appropriated, for fiscal year 2021, out of any money in the Treasury not otherwise appro- priated, $20,000,000, to remain available until Sep- tember 30, 2022, for carrying out this section.’’ § 18032. Consumer choice (a) Choice (1) Qualified individuals A qualified individual may enroll in any qualified health plan available to such indi- vidual and for which such individual is eligi- ble. (2) Qualified employers (A) Employer may specify level A qualified employer may provide support for coverage of employees under a qualified health plan by selecting any level of cov- erage under section 18022(d) of this title to be made available to employees through an Exchange. (B) Employee may choose plans within a level Each employee of a qualified employer that elects a level of coverage under sub- paragraph (A) may choose to enroll in a qualified health plan that offers coverage at that level. (b) Payment of premiums by qualified individ- uals A qualified individual enrolled in any qualified health plan may pay any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan. (c) Single risk pool (1) Individual market A health insurance issuer shall consider all enrollees in all health plans (other than grand- fathered health plans) offered by such issuer in the individual market, including those enroll- ees who do not enroll in such plans through the Exchange, to be members of a single risk pool. (2) Small group market A health insurance issuer shall consider all enrollees in all health plans (other than grand- fathered health plans) offered by such issuer in the small group market, including those en- rollees who do not enroll in such plans through the Exchange, to be members of a sin- gle risk pool. (3) Merger of markets A State may require the individual and small group insurance markets within a State to be merged if the State determines appro- priate. (4) State law A State law requiring grandfathered health plans to be included in a pool described in paragraph (1) or (2) shall not apply. (d) Empowering consumer choice (1) Continued operation of market outside Ex- changes Nothing in this title 1 shall be construed to prohibit— (A) a health insurance issuer from offering outside of an Exchange a health plan to a qualified individual or qualified employer; and (B) a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health plan offered outside of an Exchange. (2) Continued operation of State benefit re- quirements Nothing in this title 1 shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is offered outside of an Exchange to offer benefits. (3) Voluntary nature of an Exchange (A) Choice to enroll or not to enroll Nothing in this title 1 shall be construed to restrict the choice of a qualified individual to enroll or not to enroll in a qualified health plan or to participate in an Ex- change. (B) Prohibition against compelled enrollment Nothing in this title 1 shall be construed to compel an individual to enroll in a qualified health plan or to participate in an Ex- change. (C) Individuals allowed to enroll in any plan A qualified individual may enroll in any qualified health plan, except that in the case of a catastrophic plan described in section 18022(e) of this title, a qualified individual may enroll in the plan only if the individual is eligible to enroll in the plan under section 18022(e)(2) of this title. (D) Members of Congress in the Exchange (i) Requirement Notwithstanding any other provision of law, after the effective date of this sub-