Government Programs with Limited Benefits

The Individual Mandate: Who is Liable for a Penalty?


A number of government programs do not provide full coverage for medical expenses, and thus do not qualify as MEC (for example, Medicaid coverage for pregnant women or Medicaid programs that only cover family planning services, tuberculosis-related services or emergency medical conditions). The following additional types of Medicaid coverage do not qualify as MEC because they are not required to offer comprehensive coverage under the Medicaid rules:

     • Coverage for the medically needy (individuals with high medical expenses
     who would be eligible for Medicaid but for their income level)

     • Coverage under Section 1115 demonstration projects (experimental, pilot
     or demonstration projects that promote the objectives of the Medicaid program)

However, HHS and the Treasury may recognize certain medically-needy or Section 1115 demonstration project coverage to qualify as MEC, if the coverage is comprehensive.

TRICARE “space available care” and “line-of-duty-care” also would not qualify as MEC. Space available care is provided for certain individuals who are excluded from TRICARE coverage for health care services from private sector providers and only eligible for care if space is available in a facility for the uniformed services. Line-of-duty care is provided for certain individuals who are not on active duty and are entitled to episodic care for an injury, illness or disease incurred or aggravated in the line of duty.

However, because individuals enrolled in these types of coverage may not know at open enrollment for the 2014 plan year that they are not MEC, IRS Notice 2014-10 provides transition relief from the individual mandate in 2014 for these individuals. Notice 2014-10 provides that a taxpayer is not liable for the individual mandate penalty for months in 2014 when he or she is enrolled in:

     • Family planning services Medicaid

     • Tuberculosis-related services Medicaid

     • Pregnancy-related Medicaid

     • Emergency medical conditions Medicaid

     • Certain Section 1115 demonstration projects

     • Coverage for medically needy individuals

     • Space available care

     • Line-of-duty care

When determining whether a period without coverage qualifies as a short coverage gap, an individual will be treated as having MEC for any month in 2014 when that individual is eligible for the transition relief in Notice 2014-10.

The penalty will be assessed against an individual for any month during which he or she does not maintain “minimum essential coverage” (MEC) beginning in 2014 (unless an exemption applies). The requirement to maintain MEC applies to all individuals of all ages (including children), unless that individual falls within a specific exception or is exempt. An individual is treated as having coverage for a month if he or she has coverage for any one day of that month.