In the case of an eligible insured enrolled in a qualified health plan-
In this section, the term "eligible insured" means an individual-
In the case of an individual described in sectionof title 26, the individual shall be treated as having household income equal to 100 percent for purposes of applying this section.
The reduction in cost-sharing under this subsection shall first be achieved by reducing the applicable out-of pocket 1 limit under sectionof this title in the case of-
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-
The Secretary shall adjust the out-of pocket 1 limits under paragraph (1) if necessary to ensure that such limits do not cause the respective actuarial values to exceed the levels specified in clause (i).
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-
An issuer of a qualified health plan making reductions under this subsection shall notify the Secretary of such reductions and the Secretary shall make periodic and timely payments to the issuer equal to the value of the reductions.
The Secretary may establish a capitated payment system to carry out the payment of cost-sharing reductions under this section. Any such system shall take into account the value of the reductions and make appropriate risk adjustments to such payments.
If a qualified health plan under sectionof this title offers benefits in addition to the essential health benefits required to be provided by the plan, or a State requires a qualified health plan under section of this title to cover benefits in addition to the essential health benefits required to be provided by the plan, the reductions in cost-sharing under this section shall not apply to such additional benefits.
If an individual enrolls in both a qualified health plan and a plan described in section 18031(d)(2)(B)(ii)(I) 2 of this title for any plan year, subsection (a) shall not apply to that portion of any reduction in cost-sharing under subsection (c) that (under regulations prescribed by the Secretary) is properly allocable to pediatric dental benefits which are included in the essential health benefits required to be provided by a qualified health plan under section of this title.
If an individual enrolled in any qualified health plan in the individual market through an Exchange is an Indian (as defined in sectionof 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-
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-
The Secretary shall pay to the issuer of a qualified health plan the amount necessary to reflect the increase in actuarial value of the plan required by reason of this subsection.
If an individual who is an eligible insured is not lawfully present-
For purposes of this section, an individual shall be treated as lawfully present only if the individual is, and is reasonably expected to be for the entire period of enrollment for which the cost-sharing reduction under this section is being claimed, a citizen or national of the United States or an alien lawfully present in the United States.
The Secretary, in consultation with the Secretary of the Treasury, shall prescribe rules setting forth the methods by which calculations of family size and household income are made for purposes of this subsection. Such rules shall be designed to ensure that the least burden is placed on individuals enrolling in qualified health plans through an Exchange and taxpayers eligible for the credit allowable under this section.
In this section:
Any term used in this section which is also used in sectionof title 26 shall have the meaning given such term by such section.
No cost-sharing reduction shall be allowed under this section with respect to coverage for any month unless the month is a coverage month with respect to which a credit is allowed to the insured (or an applicable taxpayer on behalf of the insured) under section 36B of such title.
Any determination under this section shall be made on the basis of the taxable year for which the advance determination is made under sectionof this title and not the taxable year for which the credit under section 36B of title 26 is allowed.
1 So in original. Probably should be "out-of-pocket".
2 So in original. Probably should be "18031(d)(3)(B)(ii)(I)".
42 U.S.C. § 18071
AMENDMENTS2010-Subsec. (c)(1)(B)(i)(I). Pub. L. 111-152, §1001(b)(1)(A), substituted "94" for "90". Subsec. (c)(1)(B)(i)(II). Pub. L. 111-152, §1001(b)(1)(B)(i), substituted "87" for "80". Subsec. (c)(1)(B)(i)(III), (IV). Pub. L. 111-152, §1001(b)(1)(B)(ii), (C), added subcls. (III) and (IV) and struck out former subcl. (III). Prior to amendment, subcl. (III) read as follows: "70 percent in the case of an eligible insured described in clause (ii) or (iii) of subparagraph (A)."Subsec. (c)(2)(A). Pub. L. 111-152, §1001(b)(2)(A)(i), substituted "94" for "90".Subsec. (c)(2)(B). Pub. L. 111-152, §1001(b)(2)(B)(i), substituted "87" for "80". Subsec. (c)(2)(C). Pub. L. 111-152, §1001(b)(2)(A)(ii), (B) (ii), (C), added subpar. (C).
- The term "Secretary" means the Secretary of Housing and Urban Development.1 See References in Text note below.