42 U.S.C. § 18062

Establishment of risk corridors for plans in individual and small group markets

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(a) In general

The Secretary shall establish and administer a program of risk corridors for calendar years 2014, 2015, and 2016 under which a qualified health plan offered in the individual or small group market shall participate in a payment adjustment system based on the ratio of the allowable costs of the plan to the plan’s aggregate premiums. Such program shall be based on the program for regional participating provider organizations under part D of title XVIII of the Social Security Act [42 U.S.C. 1395w–101 et seq.].

(b) Payment methodology(1) Payments outThe Secretary shall provide under the program established under subsection (a) that if—(A) a participating plan’s allowable costs for any plan year are more than 103 percent but not more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to 50 percent of the target amount in excess of 103 percent of the target amount; and(B) a participating plan’s allowable costs for any plan year are more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount.(2) Payments inThe Secretary shall provide under the program established under subsection (a) that if—(A) a participating plan’s allowable costs for any plan year are less than 97 percent but not less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to 50 percent of the excess of 97 percent of the target amount over the allowable costs; and(B) a participating plan’s allowable costs for any plan year are less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs.(c) DefinitionsIn this section:(1) Allowable costs(A) In general

The amount of allowable costs of a plan for any year is an amount equal to the total costs (other than administrative costs) of the plan in providing benefits covered by the plan.

(B) Reduction for risk adjustment and reinsurance payments

Allowable costs shall 11 So in original. Probably should be followed by “be”. reduced by any risk adjustment and reinsurance payments received under section 22 So in original. Probably should be “sections”. 18061 and 18063 of this title.

(2) Target amount

The target amount of a plan for any year is an amount equal to the total premiums (including any premium subsidies under any governmental program), reduced by the administrative costs of the plan.

(Pub. L. 111–148, title I, § 1342, Mar. 23, 2010, 124 Stat. 211.)Editorial NotesReferences in Text

The Social Security Act, referred to in subsec. (a), 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 subchapter XVIII of chapter 7 of this title. For complete classification of this Act to the Code, see section 1305 of this title and Tables.

Notes of Decisions

Cited in 28 cases (3 in the last 5 years), 2016–2023 · leading case: Maine Cmty. Health Options v. United States, 140 S. Ct. 1308 (2020).

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Maine Cmty. Health Options v. United States, 140 S. Ct. 1308 (2020). · cites it 10× “211–212 (codified at 42 U. S. C. §18062 ). Some plans made money and paid the Government.”

Land of Lincoln Mut. Health Ins. Co. v. United States, 129 Fed. Cl. 81 (Fed. Cl. 2016). · cites it 21× “Claim by qualified health insurance plan participating in a federally-run state Exchange to damages based upon statutory or regulatory entitlement to receive “risk-corridors” payments; Section 1342 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18062 ; 45 C.F.R.…”

Moda Health Plan, Inc. v. United States, 892 F.3d 1311 (Fed. Cir. 2018). · cites it 8× “42 U.S.C. § 18062 . Briefly, section 1342 directed the Secretary of HHS to establish a program whereby participating plans whose costs of providing coverage exceeded the premiums re- ceived (as determined by a statutory formula) would be paid a share of their excess costs by the…”

Moda Health Plan, Inc. v. United States, 130 Fed. Cl. 436 (Fed. Cl. 2017). · cites it 7× “ACA § 1342 (codified at 42 U.S.C. § 18062 (2012)). Congress did not specifically appropriate funds for the risk corridors program in the ACA.”

Blue Cross & Blue Shield of North Carolina v. United States, 131 Fed. Cl. 457 (Fed. Cl. 2017). · cites it 11× “at 33; 42 U.S.C. § 18062 . Blue Cross participated in the Risk Corridors Program during 2014, 2015 arid 2016.”

Moda Health Plan, Inc. v. United States, 908 F.3d 738 (Fed. Cir. 2018). · cites it 9× “With this statutory commitment that the government "shall pay," 42 U.S.C. § 18062 (b), the nation's insurance industry provided the designated health insurance.”

Health Repub. Ins. Co. v. United States, 129 Fed. Cl. 757 (Fed. Cl. 2017). · cites it 6× “Section 1342 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18062 ; 46 C.F.R. pt. 153; Risk Corridors Program; RCFC 12(b)(1) Motion to Dismiss; Subject Matter Jurisdiction; Money-Mandating Statute and Regulation; Presently Due Money Damages; Ripeness; Agency…”

New Mex. Health Connections, Non-Profit Corp. v. U.S. Dep't of Health & Human Servs., 340 F. Supp. 3d 1112 (D.N.M. 2018). · cites it 5× “See 42 U.S.C. § 18062 . Those payments, HHS predicts, "will protect against uncertainty in rate setting for qualified health plans by limiting the extent of issuers' financial losses and gains.”

Molina Healthcare of California, Inc. v. United States, 133 Fed. Cl. 14 (Fed. Cl. 2017). · cites it 6× “ACA § 1342 (codified at 42 U.S.C. § 18062 (2012)) (emphasis added).”

Maine Cmty. Health Options v. United States, 133 Fed. Cl. 1 (Fed. Cl. 2017). · cites it 4× “This is a claim for statutory entitlement to payment under the “Risk Corridors Program” (“RCP”) created by section 1342 of the Affordable Care Act (“ACA”), codified at 42 U.S.C. § 18062 (2012) (“section 1342”).”

Gerhart v. United States Dep't of Health & Human Servs., 242 F. Supp. 3d 806 (S.D. Iowa 2017). · cites it 3× “” 42 U.S.C. § 18062 (a). Under the risk corridors program, issuers pay HHS a penalty if their claims costs are less than their premiums (minus administrative costs) by a given percentage.”

N.M. Health Connections v. U.S. Dep't of Health & Human Servs., 312 F. Supp. 3d 1164 (D.N.M. 2018). “See 42 U.S.C. § 18062 . Those payments, HHS predicts, "will protect against *1174 uncertainty in rate setting for qualified health plans by limiting the extent of issuers' financial losses and gains.”

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— 42 U.S.C. § 18062(b)(1) — 1 case

Molina Healthcare of California, Inc. v. United States, 133 Fed. Cl. 14 (Fed. Cl. 2017). “ACA § 1342 (codified at 42 U.S.C. § 18062 (2012)) (emphasis added).”

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