All posts in Health Care Reform

How Much Will the Individual Mandate Penalty Cost Me?


        The Individual Mandate: Reporting Coverage
            and Paying Penalties


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The penalty for not obtaining acceptable health care coverage is being phased in over a three-year period. The amount of the penalty is either your “flat dollar amount” or your “percentage of income amount”— whichever is greater.

For 2014, the annual penalty is either:

     • One percent of your household income that is above the tax
     return filing threshold for your filing status; or

     • Your family’s flat dollar amount, which is $95 per adult and $47.50
     per child, limited to a family maximum of $285.

Your payment amount is capped at the cost of the national average premium for a bronze level health plan, available through the Marketplace in 2014. For 2014, the annual national average premium for a bronze level health plan available through the Marketplace was $2,448 per individual ($204 per month), but $12,240 for a family with five or more members ($1,020 per month). For 2015, the annual national average premium for a bronze level health plan available through the Marketplace is $2,484 per individual ($207 per month), but $12,420 for a family with five or more members ($1,035 per month).

Calculating your payment requires you to know your household income and your tax return filing threshold.

Household income is the adjusted gross income from your tax return plus any excludible foreign earned income and tax-exempt interest you receive during the taxable year. Household income also includes the adjusted gross incomes of all of your dependents who are required to file tax returns.

Tax return filing threshold is the minimum amount of gross income an individual of your age and filing status (for example, single, married filing jointly, head of household) must make to be required to file a tax return.

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The IRS will generally assess and collect individual mandate penalties in the same manner as taxes, with certain limitations. As a result, any penalty under the individual mandate will likely be subtracted from the tax refund that the individual is owed, if any.

A key provision of the Affordable Care Act (ACA) is the individual mandate, which requires most individuals to purchase health insurance coverage for themselves and their family members or pay a penalty.

Starting in 2015, individuals will have to report on their federal tax return whether they had health insurance coverage for 2014 or were exempt from the individual mandate. Any penalties that an individual owes for not having health insurance coverage will generally be assessed and collected in the same manner as taxes.

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Who is exempt from the individual mandate?


        The Individual Mandate: Reporting Coverage
            and Paying Penalties


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You may be exempt from the individual mandate penalty if you:

     • Cannot afford coverage

     • Have income below the federal income tax filing threshold

     • Are not a citizen, are not considered a national or are not lawfully present in
     the United States

     • Experience a gap in coverage for less than a continuous three-month period

     • Qualify as a religious conscientious objector

     • Are a member of a health care sharing ministry

     • Are a member of certain American Indian tribes

     • Are given a hardship exemption by the Department of Health
     and Human Services

     • Are incarcerated

A key provision of the Affordable Care Act (ACA) is the individual mandate, which requires most individuals to purchase health insurance coverage for themselves and their family members or pay a penalty.

Starting in 2015, individuals will have to report on their federal tax return whether they had health insurance coverage for 2014 or were exempt from the individual mandate. Any penalties that an individual owes for not having health insurance coverage will generally be assessed and collected in the same manner as taxes.

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How will coverage be reported under the individual mandate?


        The Individual Mandate: Reporting Coverage
            and Paying Penalties


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Starting in 2015, when you file a federal tax return for 2014, you will have to:

     • Report that you, your spouse (if filing jointly) and any individual you claim
     as a dependent had health care coverage throughout 2014; or

     • Claim a coverage exemption from the individual mandate
     for some or all of 2014 and attach Form 8965; or

     • Pay an individual mandate penalty (called a shared responsibility payment)
     for any month in 2014 that you, your spouse (if filing jointly) or any individual
     you claim as a dependent did not have coverage and did not qualify for a
     coverage exemption.

If you and your dependents all had minimum essential coverage for each month of the tax year, you will indicate this on your 2014 tax return by simply checking a box on Form 1040, 1040A or 1040EZ; no further action is required. If you obtained a coverage exemption through your workplace, you will file Form 8965 and attach it to your tax return.

For any month you or your dependents did not have coverage or a coverage exemption, you will have to make a shared responsibility payment. The amount of the payment due will be reported on Form 1040, Line 61, in the “Other Taxes” section, and on the corresponding lines on Form 1040A and 1040EZ.

A key provision of the Affordable Care Act (ACA) is the individual mandate, which requires most individuals to purchase health insurance coverage for themselves and their family members or pay a penalty.

Starting in 2015, individuals will have to report on their federal tax return whether they had health insurance coverage for 2014 or were exempt from the individual mandate. Any penalties that an individual owes for not having health insurance coverage will generally be assessed and collected in the same manner as taxes.

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2014 Health Care Reform Court Decisions Impact on Employers


          Federal Courts Issue Conflicting Rulings
          on Subsidies in Federal Exchanges


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Following the appellate court rulings, the Obama administration indicated that federal subsidies will continue to be available to eligible individuals in all states, including those with FFEs.

This availability of subsidies may have significant implications for employers as a result of the ACA’s employer mandate. Under the employer mandate, large employers may face penalties if they do not offer coverage that meets certain requirements to their full-time employees.

However, penalties apply only if an employee receives a subsidy to buy coverage through an Exchange. If the subsidy is available only in state-based Exchanges, employers would not be subject to penalties for employees living in states with an FFE.

Several lawsuits have been filed by individuals and employers to challenge the ability of the federal government to provide tax credits under the Affordable Care Act (ACA) to individuals in states that did not establish their own Exchanges (that is, in states with federally-facilitated exchanges, or FFEs). These lawsuits were filed in response to an Internal Revenue Service (IRS) rule that authorizes subsidies in all states, including those with FFEs.

On July 22, 2014, two federal appeals courts—the District of Columbia Circuit Court and the 4th U.S. Circuit Court—issued inconsistent rulings on the availability of subsidies in states with FFEs.

In Halbig v. Burwell, the D.C. Circuit Court held that the IRS rule authorizing subsidies in states with FFEs is invalid. In a 2-1 opinion, the court ruled that the text of the ACA clearly restricts the subsidies to individuals in states that established their own Exchanges.

In King v. Burwell, the 4th Circuit Court unanimously upheld the availability of the ACA’s subsidies in states with their own Exchanges and in states with FFEs.


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Health Care Reform Court Decisions 2014


          Federal Courts Issue Conflicting Rulings
          on Subsidies in Federal Exchanges


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The lawsuits in Halbig v. Burwell and King v. Burwell were filed by individuals and employers in states that have FFEs. They argued that the IRS rule authorizing subsidies in all states conflicts with the text of the ACA. They assert that, according to the law’s plain language, the ACA only authorized subsidies to be provided in states that have established their own Exchanges.

In Halbig v. Burwell, a three-judge panel from the D.C. Circuit Court struck down the IRS’ rule that authorizes subsidies in all states, including those with FFEs. The court concluded that the ACA “unambiguously restricts” the subsidies to insurance purchased on Exchanges established by the states. Thus, the court said that subsidies are only available to individuals who obtain insurance through state-based Exchanges.

In King v. Burwell, the 4th Circuit Court ruled that the text of the ACA is ambiguous and subject to multiple interpretations. The court upheld the IRS’ rule that authorizes subsidies in all states, including those with FFEs, as a permissible exercise of the agency’s discretion. Thus, the court said that the subsidies are available to individuals who obtain insurance through either state-based Exchanges or through FFEs.

The Obama administration disagrees with the D.C. Circuit Court’s ruling and intends to seek further review of the decision. It is anticipated that the Justice Department will ask the entire 11-person D.C. appeals court to review the decision. In the meantime, a Justice Department spokesperson has stated that the subsidies will continue to remain available.

Several lawsuits have been filed by individuals and employers to challenge the ability of the federal government to provide tax credits under the Affordable Care Act (ACA) to individuals in states that did not establish their own Exchanges (that is, in states with federally-facilitated exchanges, or FFEs). These lawsuits were filed in response to an Internal Revenue Service (IRS) rule that authorizes subsidies in all states, including those with FFEs.

On July 22, 2014, two federal appeals courts—the District of Columbia Circuit Court and the 4th U.S. Circuit Court—issued inconsistent rulings on the availability of subsidies in states with FFEs.

In Halbig v. Burwell, the D.C. Circuit Court held that the IRS rule authorizing subsidies in states with FFEs is invalid. In a 2-1 opinion, the court ruled that the text of the ACA clearly restricts the subsidies to individuals in states that established their own Exchanges.

In King v. Burwell, the 4th Circuit Court unanimously upheld the availability of the ACA’s subsidies in states with their own Exchanges and in states with FFEs.


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Health Insurance Exchanges


          Federal Courts Issue Conflicting Rulings
          on Subsidies in Federal Exchanges


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Effective for 2014, the ACA requires each state to have an Exchange for individuals and small businesses to purchase private health insurance. According to the Department of Health and Human Services (HHS), the Exchanges allow for direct comparisons of private health insurance options on the basis of price, quality and other factors, and they coordinate eligibility for subsidies and other insurance affordability programs.

The ACA delegated primary responsibility for establishing the Exchanges to individual states. However, because the U.S. Congress cannot require states to implement federal laws, the ACA provides that HHS will operate the FFE in any state that refuses or is unable to set up an Exchange.

For 2014, only 16 states and the District of Columbia established their own Exchanges. HHS operates the FFEs in the remaining 34 states (in some cases with state assistance, but in most cases not).

Of the approximately 8 million people who selected private health plans from October through mid-April, over 5 million obtained coverage through an FFE. In addition, more than 4.5 million people have been determined eligible for subsidized insurance in the FFE.

Several lawsuits have been filed by individuals and employers to challenge the ability of the federal government to provide tax credits under the Affordable Care Act (ACA) to individuals in states that did not establish their own Exchanges (that is, in states with federally-facilitated exchanges, or FFEs). These lawsuits were filed in response to an Internal Revenue Service (IRS) rule that authorizes subsidies in all states, including those with FFEs.

On July 22, 2014, two federal appeals courts—the District of Columbia Circuit Court and the 4th U.S. Circuit Court—issued inconsistent rulings on the availability of subsidies in states with FFEs.

In Halbig v. Burwell, the D.C. Circuit Court held that the IRS rule authorizing subsidies in states with FFEs is invalid. In a 2-1 opinion, the court ruled that the text of the ACA clearly restricts the subsidies to individuals in states that established their own Exchanges.

In King v. Burwell, the 4th Circuit Court unanimously upheld the availability of the ACA’s subsidies in states with their own Exchanges and in states with FFEs.


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Health Care Reform: Common Acronyms



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New legislation means the addition of new health care reform terms. Use this handy reference to help decode what terms mean.There are a growing number of acronyms used in health care reform-related materials today. Here is a list of common acronyms and a definition for each.

ACA: The Affordable Care Act. Used to refer to the final, amended version of the health care reform legislation.

CDC: The Centers for Disease Control and Prevention.

CHIP: The Children’s Health Insurance Program. Program that provides health insurance to low-income children, and in some states, pregnant women who do not qualify for Medicaid but cannot afford to purchase private health insurance.

DOL: United States Department of Labor.

EBSA: Employee Benefits Security Administration. A division of the DOL responsible for compliance assistance regarding benefit plans.

EPO Plan: An exclusive provider organization plan. A managed care plan that only covers services in the plan’s network of doctors, specialists or hospitals (except in an emergency).

ERRP: The Early Retiree Reinsurance Program. A temporary program created under health care reform to provide coverage to early retirees.

FPL: Federal poverty level. A measure of income level issued annually by HHS and used to determine eligibility for certain programs and benefits.

FLSA: The Federal Fair Labor Standards Act. Amended by PPACA to incorporate health care reform-specific provisions.

FSA: Flexible spending account.

HCERA: The Health Care and Education Reconciliation Act of 2010. Enacted on March 30, 2010, to amend and supplement PPACA.

HCR: Health care reform.

HDHP: High deductible health plan.

HHS: United States Department of Health and Human Services.

HMO: Health maintenance organization. A type of health insurance plan that typically limits coverage to care from medical providers who work for or contract with the HMO.

HRA: Health reimbursement arrangement or account.

HSA: Health savings account.

IRO: An independent review organization. An organization that performs independent external reviews of adverse benefit determinations.

MLR: Medical loss ratio. Refers to the claims costs and amounts expended on health care quality improvement as a percent of total premiums. This ratio excludes taxes, fees, risk adjustments, risk corridors and reinsurance.

NAIC: The National Association of Insurance Commissioners.

OCIIO: The Office of Consumer Information and Insurance Oversight. A division of HHS responsible for implementing many of the health care reform provisions.

OOP: Out-of-pocket limit. The maximum amount you have to pay for covered services in a plan year.

PCE: Pre-existing condition exclusion. A plan provision imposing an exclusion of benefits due to a pre-existing condition.

PCIP: The Pre-existing Condition Insurance Plan. A temporary high-risk insurance pool that provided coverage to eligible individuals until 2014.

POS Plan: Point-of-service plan. A type of plan in which you pay less if you go to doctors, hospitals and other health care providers that belong to the plan’s network. POS plans require a referral from your primary care doctor to see a specialist.

PPACA: The Patient Protection and Affordable Care Act. Enacted on March 23, 2010, as the primary health care reform law.

PPO: Preferred provider organization. A type of health plan that contracts with medical providers (doctors, hospitals) to create a network of participating providers. You pay less when using providers in the plan’s network, but can use providers outside the network for an additional cost.

QHP: Qualified health plan. A certified health plan that provides an essential health benefits package. Offered by a licensed health insurer.

SHOP Exchange: The Small Business Health Options Program. A program that each health insurance exchange must create to assist eligible small employers when enrolling their employees in qualified health plans offered in the small-group market.

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Health Insurance Subsidies


          Federal Courts Issue Conflicting Rulings
          on Subsidies in Federal Exchanges


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The ACA created health insurance subsidies to help eligible individuals and families purchase health insurance through an Exchange. The subsidies are designed to make coverage through an Exchange more affordable by reducing taxpayers’ out-of-pocket premium costs.

There are two federal health insurance subsidies available with respect to coverage through an Exchange: premium tax credits and cost-sharing reductions. Both of these subsidies vary in amount based on the taxpayer’s household income, and they reduce the out-of-pocket costs of health insurance for the insured.

Premium tax credits are available for people with somewhat higher incomes (up to 400 percent of the federal poverty level (FPL)), and reduce out-of-pocket premium costs for the taxpayer.

Reduced cost-sharing is available for individuals with lower incomes (up to 250 percent of the FPL). Through cost-sharing reductions, these individuals will be eligible to enroll in plans with higher actuarial values and have the plan, on average, pay a greater share of covered benefits. This means that coverage for these individuals will have lower out-of-pocket costs at the point of service (for example, lower deductibles and copayments).

Several lawsuits have been filed by individuals and employers to challenge the ability of the federal government to provide tax credits under the Affordable Care Act (ACA) to individuals in states that did not establish their own Exchanges (that is, in states with federally-facilitated exchanges, or FFEs). These lawsuits were filed in response to an Internal Revenue Service (IRS) rule that authorizes subsidies in all states, including those with FFEs.

On July 22, 2014, two federal appeals courts—the District of Columbia Circuit Court and the 4th U.S. Circuit Court—issued inconsistent rulings on the availability of subsidies in states with FFEs.

In Halbig v. Burwell, the D.C. Circuit Court held that the IRS rule authorizing subsidies in states with FFEs is invalid. In a 2-1 opinion, the court ruled that the text of the ACA clearly restricts the subsidies to individuals in states that established their own Exchanges.

In King v. Burwell, the 4th Circuit Court unanimously upheld the availability of the ACA’s subsidies in states with their own Exchanges and in states with FFEs.


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