United States: IRS Issues Final Regulations On Individual Mandate To Maintain Healthcare Coverage

Last Updated: September 4 2013
Article by Robert B. Wynne and Larry R. Goldstein

This is the 38th in a series of WorkCite articles concerning the Patient Protection and Affordable Care Act and its companion statute, the Health Care and Education Reconciliation Act of 2010 (referred to collectively as the Act). In this article, we discuss the final regulations (Regulations) issued earlier this week by the Internal Revenue Service (IRS) addressing the Act's requirement for individuals to maintain minimum essential healthcare coverage or pay a penalty (Individual Mandate) beginning in 2014.

Background

Under Section 5000A of the Internal Revenue Code (Code), an "applicable individual" must either maintain "minimum essential coverage" (MEC) for himself or herself and any nonexempt family members or include an additional payment with his or her federal income tax return. Section 5000A has been described as the linchpin of the Act. The decision of the U.S. Supreme Court in National Federation of Independent Business v. Sebelius, 2012 U.S. LEXIS 4876 (2012), upholding the constitutionality of Section 5000A under Congress' taxing power, enabled healthcare reform under the Act to proceed.

The IRS issued proposed regulations (Proposal) under Section 5000A last February. The Proposal was the first significant guidance from the IRS as to the Individual Mandate.

In an earlier WorkCite article, we discussed the provisions of the Proposal as to who is covered by the Individual Mandate, what individuals must do to comply and how liability is calculated if an individual failed to maintain MEC.

The Regulation includes most of the provisions in the Proposal and clarifies certain healthcare coverage options that qualify as MEC and elaborates on several of the exemptions from the Individual Mandate. The preamble to the Regulation addresses future IRS guidance to be issued.

Healthcare Coverage Options Qualifying as MEC

Several provisions of the Regulation or its preamble clarify the Proposal's broad definition of what constitutes MEC. The following qualify as MEC under the Regulation:

  • Self-insured group health plans: A self-insured group health plan qualifies as an eligible employer-sponsored plan.
  • Nonappropriated Fund Health Benefits Program: Although the Proposal generally provided that a governmental-sponsored program was not an eligible employer-sponsored plan, the Regulation acknowledges the existence of certain individuals who are eligible for MEC under government-sponsored plans by reason of employment with the U.S. Government, including the Department of Defense's Nonappropriated Fund Health Benefits Program.
  • Exchange-provided qualified health plans: Qualified health plans offered through the health insurance exchanges being established under the Act are "plans in the individual market" for purposes of qualifying as MEC.
  • Exchange-provided qualified health plans offered in U.S. territories: The Act provides that a U.S. territory electing to establish a health insurance exchange is treated as a state for applying basic regulations under the Act. The Regulation clarifies that a qualified health plan offered through an exchange established by and within a U.S. territory is treated as a "plan in the individual market" within a state.
  • Medicaid benefits suspended while incarcerated: An individual incarcerated pending disposition of charges whose Medicaid benefits have been suspended.
  • Medicaid premium assistance programs: Coverage under a Medicaid premium assistance program for certain individuals.
  • Plans offered on behalf of employers: Plans offered to employees on behalf of employers (such as multiemployer plans or single-employer collectively-bargained plans)

Exemptions for Certain Applicable Individuals

The Regulation or its preamble clarify several of the exemptions from the Individual Mandate for certain applicable individuals.

  • Additional hardship exemptions: Applicable individuals may claim hardship exemptions under the following two scenarios:

    • A taxpayer is not required to file an income tax return because his or her gross income is below the applicable return filing threshold, but the taxpayer files a return nevertheless, claiming a dependent (who has a filing requirement) and, as a result, had household income exceeding the applicable filing threshold.
    • Employed family members who are eligible for affordable employer-sponsored self-only coverage, but for whom the aggregate cost of employer-sponsored coverage for all employed members of the family is unaffordable.
  • Unaffordable coverage exemption for retirees: For purposes of the unaffordable coverage exemption from the Individual Mandate (which is available for individuals who cannot afford coverage because the premium cost is greater than 8 percent of household income), one is not considered eligible for retiree coverage unless he or she enrolls. This means that an individual who is eligible for retiree coverage but does not enroll disregards that eligibility in determining his or her qualification for the unaffordable coverage exemption.
  • Short coverage gap: Gaps in coverage prior to Jan. 1, 2014 are not taken into account when measuring the length of a coverage gap in 2014.

Anticipated Future Guidance

The IRS anticipates issuing guidance that will provide individuals an exemption from the Individual Mandate penalties for any month in which they are covered by any of the following types of coverage in 2014 (which currently do not qualify as MEC under the Regulation):

  • Pregnancy-related Medicaid coverage
  • Coverage under a limited-benefit TRICARE program for active and retired military personnel and their dependents
  • Certain coverage under certain demonstration projects under Section 1115 of the Social Security Act authorized by the Department of Health and Human Services to test new or existing approaches to financing and delivering Medicaid

Additional future IRS guidance will address the following:

  • Other government-sponsored plans qualifying for MEC as eligible employer-sponsored plans
  • Arrangements in which an employer provides subsidies or funds a pre-tax arrangement for employees to use to obtain coverage under plans offered in the individual market
  • Whether Medicaid coverage provided to medically-needy individuals is MEC
  • How individuals may claim the exemption for being not lawfully present in the U.S.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on Mondaq.com.

Click to Login as an existing user or Register so you can print this article.

Authors
Similar Articles
Relevancy Powered by MondaqAI
Reinhart Boerner Van Deuren s.c.
 
In association with
Related Topics
 
Similar Articles
Relevancy Powered by MondaqAI
Reinhart Boerner Van Deuren s.c.
Related Articles
 
Related Video
Up-coming Events Search
Tools
Print
Font Size:
Translation
Channels
Mondaq on Twitter
 
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
 
Email Address
Company Name
Password
Confirm Password
Position
Mondaq Topics -- Select your Interests
 Accounting
 Anti-trust
 Commercial
 Compliance
 Consumer
 Criminal
 Employment
 Energy
 Environment
 Family
 Finance
 Government
 Healthcare
 Immigration
 Insolvency
 Insurance
 International
 IP
 Law Performance
 Law Practice
 Litigation
 Media & IT
 Privacy
 Real Estate
 Strategy
 Tax
 Technology
 Transport
 Wealth Mgt
Regions
Africa
Asia
Asia Pacific
Australasia
Canada
Caribbean
Europe
European Union
Latin America
Middle East
U.K.
United States
Worldwide Updates
Registration (you must scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions

Mondaq.com (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of www.mondaq.com

To Use Mondaq.com you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these Terms or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.

Disclaimer

The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use of the Content or performance of Mondaq’s Services.

General

Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions