U.S. Code
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Title 42
» Chapter CHAPTER 157— QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS › Subchapter SUBCHAPTER III— AVAILABLE COVERAGE CHOICES FOR ALL AMERICANS › Part Part E— Reinsurance and Risk Adjustment
42 U.S.C. § 18063
Risk adjustment
(a) In general(1) Low actuarial risk plansUsing the criteria and methods developed under subsection (b), each State shall assess a charge on health plans and health insurance issuers (with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all plans or coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974 [29 U.S.C. 1001 et seq.]).
(2) High actuarial risk plansUsing the criteria and methods developed under subsection (b), each State shall provide a payment to health plans and health insurance issuers (with respect to health insurance coverage) described in subsection (c) if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).
(b) Criteria and methodsThe Secretary, in consultation with States, shall establish criteria and methods to be used in carrying out the risk adjustment activities under this section. The Secretary may utilize criteria and methods similar to the criteria and methods utilized under part C or D of title XVIII of the Social Security Act [42 U.S.C. 1395w–21 et seq., 1395w–101 et seq.]. Such criteria and methods shall be included in the standards and requirements the Secretary prescribes under section 18041 of this title.
(c) ScopeA health plan or a health insurance issuer is described in this subsection if such health plan or health insurance issuer provides coverage in the individual or small group market within the State. This subsection shall not apply to a grandfathered health plan or the issuer of a grandfathered health plan with respect to that plan.
(Pub. L. 111–148, title I, § 1343, Mar. 23, 2010, 124 Stat. 212.)Editorial NotesReferences in TextThe Employee Retirement Income Security Act of 1974, referred to in subsec. (a), is Pub. L. 93–406, Sept. 2, 1974, 88 Stat. 829, which is classified principally to chapter 18 (§ 1001 et seq.) of Title 29, Labor. For complete classification of this Act to the Code, see Short Title note set out under section 1001 of Title 29 and Tables.
The Social Security Act, referred to in subsec. (b), is act Aug. 14, 1935, ch. 531, 49 Stat. 620. Parts C and D of title XVIII of the Act are classified generally to parts C (§ 1395w–21 et seq.) and D (§ 1395w–101 et seq.), respectively, 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
New Mexico Health Connections v. HHS, 946 F.3d 1138 (10th Cir. 2019).
· cites it 8× “See 42 U.S.C. § 18063 . 3 The program transfers 1 Health benefit exchanges “make available qualified health plans to qualified individuals and qualified employers” in a state.”
Minuteman Health, Inc. v. U.S. Dep't of Health & Human Servs., 291 F. Supp. 3d 174 (D.D.C. 2018).
· cites it 5× “§ 706 , and (2) were beyond HHS's statutory authority because they contravene the statute providing for risk adjustment, 42 U.S.C. § 18063 . The issues posed in this lawsuit are far from simple.”
UnitedHealthcare of New York v. Lacewell, 967 F.3d 82 (2d Cir. 2020).
· cites it 2× “risk adjustment activities,” 42 U.S.C. § 18063 (b). In general, 8 risk adjustment in health insurance markets is designed to “foster a stable 9 marketplace” by “provid[ing] payments to health insurance issuers that cover 10 higher-risk populations and to more evenly spread the…”
UnitedHealthcare of N.Y., Inc. v. Vullo, 323 F. Supp. 3d 470 (S.D. Ill. 2018).
“42 U.S.C. § 18063 . In accordance with this mandate, HHS promulgated regulations establishing the FRAP and rules that would govern the FRAP's administration.”
Vista Health Plan v. HHS, 29 F.4th 210 (5th Cir. 2022).
· cites it 2× “To counteract this, Congress enacted 42 U.S.C. § 18063 , which directs HHS to establish a permanent risk-adjustment program.”
Vista Health Plan v. HHS, 31 F.4th 946 (5th Cir. 2022).
· cites it 2× “To counteract this, Congress enacted 42 U.S.C. § 18063 , which directs HHS to establish a risk-adjustment program.”
Conway v. Friday Health Plans of Colorado, Inc. (D. Colo. 2025).
· cites it 2× “42 U.S.C. § 18063 (a). It “is intended to provide increased payments to health insurance issuers that attract higher-risk populations, such as those with chronic conditions, and reduce the incentives for issuers to avoid higher-risk enrollees.”
Conway v. United States (Fed. Cl. 2019).
“42 U.S.C. § 18063 . That governmental entity then redistributes those payments to insurers whose plans bear high actuarial risk.”
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