Patient Protection and Affordable Care Act — Table of contents and statutory structure
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This document is the statutory text (or table of contents and section headings) of the Patient Protection and Affordable Care Act describing titles, subtitles, parts, and major sections; it governs federal health care reform provisions and affects insurers, employers, states, and individuals subject to the Act.
Statutory Coverage Criteria and Program Rules
Coverage-related headings
This excerpt lists statutory headings that define coverage-related areas but does not provide specific coverage criteria in this portion.
Indexed coverage provisions
Key coverage provisions and program options referenced in these sections include:
Referenced program integrity and administrative requirements
Referenced sections that may impose eligibility, enrollment, or documentation requirements:
Coverage and consumer protection criteria
Minimum coverage requirements for preventive services and limits on benefit caps.
Qualified high-risk pool criteria and limits
Temporary qualified high-risk pool program for uninsured individuals with preexisting conditions (through Jan 1, 2014) including funding, eligibility, benefit and rating rules, appeals, and transition to Exchanges.
Premium review and disclosure criteria
Premium review and monitoring processes to identify unreasonable premium increases and provide grants to States to support review and recommendations.
Early retiree reinsurance coverage criteria
Temporary reinsurance program for early retirees to reimburse participating employment-based plans for high-cost claims.
Affordable coverage internet portal and disclosure format
Internet portal requirement to identify affordable coverage options and standardized format for presenting coverage information.
Certification, compliance, audits and rulemaking
Health plan certification, documentation, testing, audits, and compliance with revised standards and operating rules.
Nondiscrimination and market rules
Nondiscrimination and market conduct requirements related to premiums, availability, renewability, and eligibility.
Coverage rules and requirements from extracted PPACA sections
Extracted provisions include renewability, nondiscrimination, wellness program rules and limits, preservation of existing coverage, rating uniformity, effective dates, qualified plan criteria, and essential health benefits requirements.
Coverage criteria and special rules
Coverage requirements and special rules extracted from SEC.1302-1303:
Exchange Coverage Criteria
Criteria for qualified health plans and Exchange offerings:
Community Health Insurance Option coverage criteria
Rules and requirements for benefits, cost-sharing, premiums, and provider reimbursement for a community health insurance option:
Basic Health Program criteria
Basic Health Program coverage and funding criteria
Waiver criteria and processes
State innovation waiver requirements and processes
Multi-state and nationwide plan coverage stance
Multi‑state plans and nationwide qualified health plan rules
Nationwide Plan Offering Criteria
Nationwide qualified health plans:
Reinsurance Program Criteria
Transitional reinsurance program (2014-2016):
Risk Corridors
Risk corridors (2014-2016) and definitions:
Risk Adjustment
Risk adjustment:
Premium Tax Credit Criteria
Premium tax credit (section 36B):
Cost‑sharing reduction and eligibility criteria (statutory)
Criteria for cost‑sharing reductions for eligible insureds enrolled in silver plans and their interaction with actuarial values and out‑of‑pocket limits:
Advance premium tax credit and related eligibility/payment criteria
Advance determinations and payments for premium tax credits and cost-sharing reductions:
Referenced Codes, Thresholds, and Numeric Limits
| Misvalued codes under the physician fee schedule (section references) |
| Medicare Part D formulary and coverage gap provisions |
| Redesignation of sections within Part A of the Public Health Service Act (section numbers shifted) |
| Reimbursement %: 80% | Secretary reimburses 80% of portion of costs exceeding $15,000 for valid early retiree reinsurance claims |
| Claim floor/ceiling | Claims eligible for reimbursement must be >= $15,000 and <= $90,000 (amounts adjusted annually) |
| ASC X12 835 | Health Care Payment and Remittance Advice standard referenced for electronic remittance |
| No codes listed |
| Single risk pool requirement for individual and small group markets (excluding grandfathered plans). |
| Individuals enrolled in community health insurance option eligible for premium tax credits under section 36B. |
| Essential health benefits must be included for nationwide qualified health plans (per section 1302). |
| List of at least 50 but not more than 100 medical conditions or comparable objective identification methods (diagnostic/procedure codes) for high-risk individuals. |
| 45R | Internal Revenue Code section establishing small employer health insurance credit (employee health insurance expenses of small employers). |
Provider Responsibilities, Enrollment, and Operational Deadlines
Presumptive Eligibility by Hospitals
Hospitals may determine and temporarily enroll individuals in presumptive Medicaid eligibility for all Medicaid‑eligible populations based on hospital‑conducted presumptive eligibility determinations. Providers must follow state procedures and documentation requirements when making presumptive eligibility determinations and promptly submit full Medicaid applications for continued coverage.
- Hospitals must use State‑approved methodologies and forms
- Presumptive eligibility is temporary and requires submission of full application for ongoing coverage
PA Ordering of Post‑Hospital Extended Care Services
Physician assistants (PAs) are permitted to order post‑hospital extended care services (e.g., skilled nursing facility or home health) where state law and payer policies allow. Orders must meet documentation standards and comply with Medicare/Medicaid enrollment and medical necessity requirements.
- Confirm state scope‑of‑practice and payer acceptance of PA orders
- Include clinical rationale and supporting documentation with orders
Medicare, Medicaid, and CHIP Program Integrity Provisions
Medicare, Medicaid, and CHIP include enhanced program integrity measures requiring provider screening, enrollment, enhanced penalties, mandatory reporting to program integrity databases, limits on claim submission windows, and expanded audit authority (including Recovery Audit Contractors). Providers must comply with enrollment, documentation, and reporting requirements to avoid payment delays or sanctions.
- Provider screening and revalidation required prior to billing
- Timely submission of claims (max 12 months in some provisions)
- Expanded audit and overpayment recovery authorities
Provider Screening and Enrollment; Physician Enrollment Requirements
Providers and suppliers must complete required screening and enrollment (including physician enrollment when ordering items or services) to bill Medicare, Medicaid, and CHIP. Enrollment rules include disclosure of ownership/management affiliations, registration for billing agents/clearinghouses, and compliance with State Medicaid termination provisions.
- Physicians ordering Medicare items/services must be enrolled as Medicare physicians or eligible professionals
- Billing agents/clearinghouses must register under Medicaid where required
- Noncompliance can lead to termination or exclusion from programs
Program Integrity and Anti‑Fraud Provisions
Anti‑fraud and program integrity provisions prohibit false statements and representations, require development of model reporting forms, and preserve applicability of State laws to combat fraud. Providers must maintain accurate records and promptly report suspected fraud or abuse.
- False or fraudulent information may incur civil and criminal penalties
- Use model reporting forms when adopted; comply with State anti‑fraud statutes
State Designation and Duties for Consumer Assistance / Ombudsman
States must designate an independent office of health insurance consumer assistance or an ombudsman to receive grants and assist consumers. Duties include helping file complaints and appeals, tracking consumer issues, educating consumers, assisting with enrollment, and resolving premium tax credit problems.
- State designation of an independent office is required for grant eligibility
- Ombudsman assists with appeals, enrollment, education, and premium tax credit issues
Issuer Premium Increase Justification and Disclosure
Issuers must submit justifications for unreasonable premium increases to the Secretary and relevant State prior to implementation, prominently post justifications on issuer websites, and the Secretary shall ensure public disclosure. States must share premium trend information with the Secretary and may recommend exclusion from Exchanges for patterns of excessive increases.
- Justification required before implementing an unreasonable premium increase (starting 2010 plan year)
- Public posting of justifications on issuer websites
- Secretary and States monitor premium increases beginning in later plan years
Requirements for Participating Employment‑Based Plans (Reinsurance)
Participating employment‑based plans seeking reimbursement under the temporary reinsurance program for early retirees must apply to the Secretary, implement cost‑savings programs for high‑cost conditions, provide documentation of actual medical claims costs, and be certified by the Secretary. Claims for reimbursement must be based on actual amounts expended.
- Plans must submit applications and required documentation to Secretary
- Claims must document actual costs for early retirees and dependents
- Plans must implement chronic/high‑cost condition cost‑savings programs
Operating Rules Deadlines (Eligibility, EFT, Claims, Enrollment)
Adopted operating rules deadlines: eligibility & claim status rules adopted by July 1, 2011 and effective Jan 1, 2013; EFT & remittance advice rules adopted by July 1, 2012 and effective Jan 1, 2014; claims/encounter/enrollment/premium/referral/authorization rules adopted by July 1, 2014 and effective Jan 1, 2016. The Secretary will promulgate interim final rules and accept public comments.
- Eligibility & claim status operating rules: adopt by 7/1/2011; effective 1/1/2013
- EFT & remittance advice rules: adopt by 7/1/2012; effective 1/1/2014
- Claims/encounter/enrollment/premium/referral rules: adopt by 7/1/2014; effective 1/1/2016
Emergency Department Coverage and Prior Authorization
Emergency services must be covered without prior authorization when provided in an emergency department; plans may not apply more restrictive prior authorization or cost‑sharing for out‑of‑network emergency services than for in‑network services. Cost‑sharing parity and protections for emergency care apply regardless of contractual relationships.
- No prior authorization required for emergency services in ED
- If services are out‑of‑network, cost‑sharing cannot exceed in‑network level
- Plans may not impose more restrictive coverage limits on ED emergency services
Exchange Funding and Prohibitions on Wasteful Expenditures
Exchanges must be self‑sustaining (no federal operations funding after Jan 1, 2015) and may charge assessments or user fees; Exchanges are prohibited from using operational funds for wasteful expenditures (staff retreats, promotional giveaways, excessive executive compensation, or legislative advocacy).
- Exchange must be self‑sustaining beginning 1/1/2015 (may charge assessments/user fees)
- Prohibited uses include staff retreats, promotional giveaways, excessive executive compensation, and promotion of legislative/regulatory changes
Navigator Program Requirements
Navigator program requirements: Exchanges establish a grant program to fund navigators who provide public education, fair/impartial enrollment assistance, referrals to consumer assistance/ombudsman, and culturally/linguistically appropriate information. Navigators may not be health insurance issuers or receive consideration from issuers; the Secretary will set standards to avoid conflicts of interest.
- Navigators conduct outreach, distribute impartial information, facilitate enrollment, and provide referrals
- Navigators cannot be issuers or accept payments from issuers
- Standards will ensure navigators are qualified and avoid conflicts of interest
Performance‑Based Fee Adjustments and Non‑Renewal
For contracting administrators of the community health insurance option, the Secretary may increase or reduce administrative fees (up to +10% or −50%) based on performance in areas such as maintaining low premiums and cost‑sharing, reducing administrative costs, promoting clinical quality, and providing high‑quality customer service. Contracts may not be renewed after multiple fee reductions.
- Fee may be increased up to 10% or reduced up to 50% based on performance
- Non‑renewal if assessed more than one fee reduction during the contract period
Secretary Rulemaking for Nationwide Plans
The Secretary will issue rules, in consultation with NAIC, governing the offering of nationwide qualified health plans; nationwide plans must meet licensing, filing, and state compliance requirements and may be offered only after the Secretary's rules take effect.
- Issuer must be licensed in each State where plan is offered and file forms at least 3 months prior to offering
- Secretary to issue rules in consultation with NAIC before nationwide plans may be offered
Issuer Actions for Cost‑Sharing Reductions
Issuers of qualified health plans that receive advance payments for cost‑sharing reductions must reduce cost‑sharing for eligible enrollees and notify the Secretary and Exchange. The Secretary will make periodic payments to issuers equal to the value of the reductions and may establish capitated payment systems with appropriate risk adjustment.
- Issuer must notify Secretary when making cost‑sharing reductions
- Secretary makes periodic payments to issuers equal to value of reductions; capitated payment options may be used
- Issuers must reflect advance payments in premium billing and notify Exchange/Secretary of reductions
Statutory Definitions and Term Clarifications
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