INDIVIDUAL MANDATE
The Individual Mandate provision of the ACA requires U.S. citizens and legal residents to have qualifying health coverage, beginning January 1, 2014. Qualifying coverage, which must include an “essential health benefits” (EHB) package, is equivalent to the bronze plan, the lowest-end health plan in the state insurance exchanges.
The fee for not having health insurance in 2016 & 2017
The fee is calculated 2 different ways – as a percentage of your household income, and per person. You’ll pay whichever is higher.
Percentage of income
2.5% of household income
Maximum: Total yearly premium for the national average price of a Bronze plan sold through the Marketplace
Per person
$695 per adult
$347.50 per child under 18
Maximum: $2,085
Exemptions
Exemptions will be granted for the following:
- financial hardship
- religious objections
- American Indians
- those without coverage for less than three months
- undocumented immigrants
- incarcerated individuals
- those for whom the lowest cost plan option exceeds 8% of an individual’s income, and
- those with incomes below the tax filing threshold (in 2009 the threshold for taxpayers under age 65 was $9,350 for singles and $18,700 for couples).
Individuals with the following coverage will also satisfy the requirement:
- Medicare
- Medicaid or the Children’s Health Insurance
- Program (CHIP)
- TRICARE (for service members, retirees and their families), and
- the veteran’s health program.
Eligibility process for exemptions
Exchanges are required to use an application established by the U.S. Department of Health and Human Services (HHS) to collect information necessary for determining eligibility for and granting certificates of exemption. In addition, Exchanges are required to provide timely written notice to an applicant of any eligibility determination. In the case of a determination that an applicant is eligible for an exemption, the notification must include the exemption certificate number for the purposes of tax administration.
Verification process related to eligibility for exemptions
Exchanges must undertake a series of steps to determine an applicant’s eligibility for the exemption for which he or she applied. In addition, the rule provides procedures for the Exchange to follow in the event they are unable to verify information necessary to make an eligibility determination for an exemption.
Other coverage that qualifies as minimum essential coverage
The rule provides that the following types of coverage are designated as minimum essential coverage:
- self-funded student health coverage
- refugee medical assistance supported by the Administration for Children and Families
- Medicare advantage plans, and
- state high-risk pools.
In addition, the HHS may recognize other types of coverage, which are not on the above list, as minimum essential coverage provided that HHS determines the coverage meets certain substantive and procedural requirements.
Also see the individual mandate flyer.