{"identifier":"/us/usc/t42/s18021","title":42,"num":"\u00a7\u202f18021.","heading":"Qualified health plan defined","text":"\u00a7\u202f18021.\nQualified health plan defined\n(a)\nQualified health plan\nIn this title:\n(1)\nIn general\nThe term \u201cqualified health plan\u201d means a health plan that\u2014\n(A) has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in\nsection 18031(c) of this title\n(B) provides the essential health benefits package described in\nsection 18022(a) of this title\n(C) is offered by a health insurance issuer that\u2014\n(i) is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title;\n1\n(ii) agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange;\n(iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and\n(iv) complies with the regulations developed by the Secretary under\nsection 18031(d) of this title\n(2)\nInclusion of CO\u2013OP plans and multi-State qualified health plans\nAny reference in this title\n1\nsection 18042 of this title\nsection 18054 of this title\n(3)\nTreatment of qualified direct primary care medical home plans\nThe Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.\n(4)\nVariation based on rating area\nA qualified health plan, including a multi-State qualified health plan, may as appropriate vary premiums by rating area (as defined in\nsection 300gg(a)(2) of this title\n(b)\nTerms relating to health plans\nIn this title:\n(1)\nHealth plan\n(A)\nIn general\nThe term \u201chealth plan\u201d means health insurance coverage and a group health plan.\n(B)\nException for self-insured plans and MEWAs\nExcept to the extent specifically provided by this title,\n1\nsection 1144 of title 29\n(2)\nHealth insurance coverage and issuer\nThe terms \u201chealth insurance coverage\u201d and \u201chealth insurance issuer\u201d have the meanings given such terms by\nsection 300gg\u201391(b) of this title\n(3)\nGroup health plan\nThe term \u201cgroup health plan\u201d has the meaning given such term by\nsection 300gg\u201391(a) of this title","url":"https://projectusc.org/usc/t42/s18021.html","content":[{"t":"sec","id":"/us/usc/t42/s18021","children":[{"t":"num","text":"\u00a7\u202f18021."},{"t":"heading","text":"Qualified health plan defined"},{"t":"subsec","id":"/us/usc/t42/s18021/a","children":[{"t":"num","text":"(a)"},{"t":"heading","text":"Qualified health plan"},{"t":"chapeau","text":"In this title:\u202f","children":[{"t":"ref","text":"1"},{"t":"num","text":"1","tail":"\u202fSee References in Text note below."},{"t":"text","text":"\u202fSee References in Text note below."}]},{"t":"para","id":"/us/usc/t42/s18021/a/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"In general"},{"t":"chapeau","text":"The term \u201cqualified health plan\u201d means a health plan that\u2014"},{"t":"subpara","id":"/us/usc/t42/s18021/a/1/A","children":[{"t":"num","text":"(A)"},{"t":"content","text":" has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in ","children":[{"t":"ref","text":"section 18031(c) of this title","href":"/us/usc/t42/s18031/c","tail":" issued or recognized by each Exchange through which such plan is offered;"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s18021/a/1/B","children":[{"t":"num","text":"(B)"},{"t":"content","text":" provides the essential health benefits package described in ","children":[{"t":"ref","text":"section 18022(a) of this title","href":"/us/usc/t42/s18022/a","tail":"; and"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s18021/a/1/C","children":[{"t":"num","text":"(C)"},{"t":"chapeau","text":" is offered by a health insurance issuer that\u2014"},{"t":"clause","id":"/us/usc/t42/s18021/a/1/C/i","children":[{"t":"num","text":"(i)"},{"t":"content","text":" is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title;\u202f","children":[{"t":"text","text":"1"}],"tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s18021/a/1/C/ii","children":[{"t":"num","text":"(ii)"},{"t":"content","text":" agrees to offer at least one qualified health plan in the silver level and at least one plan in the gold level in each such Exchange;","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s18021/a/1/C/iii","children":[{"t":"num","text":"(iii)"},{"t":"content","text":" agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and","tail":"\n"}],"tail":"\n"},{"t":"clause","id":"/us/usc/t42/s18021/a/1/C/iv","children":[{"t":"num","text":"(iv)"},{"t":"content","text":" complies with the regulations developed by the Secretary under ","children":[{"t":"ref","text":"section 18031(d) of this title","href":"/us/usc/t42/s18031/d","tail":" and such other requirements as an applicable Exchange may establish."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s18021/a/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Inclusion of CO\u2013OP plans and multi-State qualified health plans"},{"t":"content","children":[{"t":"p","text":"Any reference in this title\u202f","children":[{"t":"text","text":"1","tail":" to a qualified health plan shall be deemed to include a qualified health plan offered through the CO\u2013OP program under "},{"t":"ref","text":"section 18042 of this title","href":"/us/usc/t42/s18042","tail":", and a multi-State plan under "},{"t":"ref","text":"section 18054 of this title","href":"/us/usc/t42/s18054","tail":", unless specifically provided for otherwise."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s18021/a/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Treatment of qualified direct primary care medical home plans"},{"t":"content","children":[{"t":"p","text":"The Secretary of Health and Human Services shall permit a qualified health plan to provide coverage through a qualified direct primary care medical home plan that meets criteria established by the Secretary, so long as the qualified health plan meets all requirements that are otherwise applicable and the services covered by the medical home plan are coordinated with the entity offering the qualified health plan.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s18021/a/4","children":[{"t":"num","text":"(4)"},{"t":"heading","text":"Variation based on rating area"},{"t":"content","children":[{"t":"p","text":"A qualified health plan, including a multi-State qualified health plan, may as appropriate vary premiums by rating area (as defined in ","children":[{"t":"ref","text":"section 300gg(a)(2) of this title","href":"/us/usc/t42/s300gg/a/2","tail":")."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subsec","id":"/us/usc/t42/s18021/b","children":[{"t":"num","text":"(b)"},{"t":"heading","text":"Terms relating to health plans"},{"t":"chapeau","text":"In this title:\u202f","children":[{"t":"text","text":"1"}]},{"t":"para","id":"/us/usc/t42/s18021/b/1","children":[{"t":"num","text":"(1)"},{"t":"heading","text":"Health plan"},{"t":"subpara","id":"/us/usc/t42/s18021/b/1/A","children":[{"t":"num","text":"(A)"},{"t":"heading","text":"In general"},{"t":"content","children":[{"t":"p","text":"The term \u201chealth plan\u201d means health insurance coverage and a group health plan.","tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"subpara","id":"/us/usc/t42/s18021/b/1/B","children":[{"t":"num","text":"(B)"},{"t":"heading","text":"Exception for self-insured plans and MEWAs"},{"t":"content","children":[{"t":"p","text":"Except to the extent specifically provided by this title,","children":[{"t":"text","text":"1","tail":" the term \u201chealth plan\u201d shall not include a group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to State insurance regulation under "},{"t":"ref","text":"section 1144 of title 29","href":"/us/usc/t29/s1144","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s18021/b/2","children":[{"t":"num","text":"(2)"},{"t":"heading","text":"Health insurance coverage and issuer"},{"t":"content","children":[{"t":"p","text":"The terms \u201chealth insurance coverage\u201d and \u201chealth insurance issuer\u201d have the meanings given such terms by ","children":[{"t":"ref","text":"section 300gg\u201391(b) of this title","href":"/us/usc/t42/s300gg\u201391/b","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"para","id":"/us/usc/t42/s18021/b/3","children":[{"t":"num","text":"(3)"},{"t":"heading","text":"Group health plan"},{"t":"content","children":[{"t":"p","text":"The term \u201cgroup health plan\u201d has the meaning given such term by ","children":[{"t":"ref","text":"section 300gg\u201391(a) of this title","href":"/us/usc/t42/s300gg\u201391/a","tail":"."}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"}],"tail":"\n"},{"t":"text","text":"\n"},{"t":"text","text":"\n"}]}]}