Source: http://www.annalsofhealthlaw.com/annalsofhealthlaw/vol__24_issue_2?pg=39&lm=1511288559000
Timestamp: 2020-07-05 02:53:02
Document Index: 12884297

Matched Legal Cases: ['§ 300', '§ 300', '§ 300', '§ 300', '§ 300', '§ 300', '§ 300', '§ 300', '§ 300', '§ 18061', '§ 18062', '§ 18063', '§ 18071', '§ 18031', '§ 18022']

include guaranteed issue and prohibitions on exclusions based on pre-existing conditions and health risks, prohibitions on lifetime and annual benefit limits, as well as requirements for plan actuarial values, medical loss ratios, risk adjustments, and data reporting.18 The exchanges may be established or operated by a state, the federal government, or a federal-state cooperative arrangement of various types.19 This article refers to the ACA plans required to meet these conditions as “ACA plans,” whether they are offered through an exchange or in the ordinary insurance market.
To assure consistency in benefit design, the ACA requires ACA plans
to cover ten categories of health services, called Essential Health Benefits
(“EHB”).20 The Act defines EHB as ten broad categories of benefits:
( 1) Ambulatory patient services;
287, and 113-291) (establishing the Exchanges and noting that these requirements do not apply to large group plans or employer-sponsored self-insured or grandfathered plans).
18. 45 C.F.R. Pt. 155 (2014) (establishing the exchanges); 45 C.F.R. Pt. 156 (2014) (listing the requirements for insurers offering qualified health plans on exchanges); 42 U.S. C. A § 300gg (prohibiting discriminatory premium rates); § 300gg- 1 (requiring health insurance issuers to accept every employer and individual that applies for coverage); § 300gg-3 (prohibiting preexisting condition exclusion); § 300gg-2 (guaranteeing that health insurance coverage is renewable); § 300gg-5 (requiring non-discrimination in health care); § 300gg-11 (prohibiting establishment of annual/lifetime limits on the dollar value of benefits); § 300gg-13 (requiring minimum coverage for preventive health services and prohibiting cost sharing in various situations); § 300gg-14 (allowing dependent children to stay on their parents health plan until 26 years of age); § 300gg-19 (requiring an effective internal appeals process); 42 U.S. C. A. § 18061 (West, WestlawNext through P.L. 113-296, excluding P.L. 113-235, 113-287, and 113-291) (providing a transitional reinsurance program); 42 U.S. C. A. § 18062 (establishing a program of risk corridors); 42 U.S. C. A. § 18063 (establishing criteria and methods for low and high actuarial risk plans); 42 U.S. C. A. § 18071 (implementing income-based cost sharing reductions). ACA plans meeting the conditions can be approved as “qualified plans” that can be sold through the marketplace exchanges. § 18031(c) (establishing criteria for qualified health plans).
19. State Health Insurance Marketplace Types, 2015, KAISER FAM. FOUND., http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/ (last visited Apr. 13, 2015); Sarah J. Dash & Amy Thomas, New State-Based Marketplaces Unlikely in 2015, but Technology Challenges Create More Shades of Gray, THE COMMONWEALTH FUND BLOG (May 1, 2014), http://www.commonwealthfund.org/ publications/blog/2014/may/new-state-based-marketplaces-unlikely-in-2015; accord Abbe R. Gluck, Intrastatutory Federalism and Statutory Interpretation: State Implementation of Federal Law in Health Reform and Beyond, 121 Yale L.J. 534 (2011) (discussing variations in exchanges and Medicaid programs as examples of evolving conceptions of federalism).
20. § 18022(b)( 1).