26 USC 5000A - Requirement to maintain minimum essential coverage

United States Code

USC most recently checked for updates: Mar 22, 2023

Chapter 47 - CERTAIN GROUP HEALTH PLANS

Chapter 49 - COSMETIC SERVICES

U.S. Code
Notes

§ 5000A.

Requirement to maintain minimum essential coverage

(a)

Requirement to maintain minimum essential coverage

An applicable individual shall for each month beginning after 2013 ensure that the individual, and any dependent of the individual who is an applicable individual, is covered under minimum essential coverage for such month.

(b)

Shared responsibility payment

(1)

In general

If a taxpayer who is an applicable individual, or an applicable individual for whom the taxpayer is liable under paragraph (3), fails to meet the requirement of subsection (a) for 1 or more months, then, except as provided in subsection (e), there is hereby imposed on the taxpayer a penalty with respect to such failures in the amount determined under subsection (c).

(2)

Inclusion with return

Any penalty imposed by this section with respect to any month shall be included with a taxpayer’s return under chapter 1 for the taxable year which includes such month.

(3)

Payment of penalty

If an individual with respect to whom a penalty is imposed by this section for any month—

(A)

is a dependent (as defined in section 152) of another taxpayer for the other taxpayer’s taxable year including such month, such other taxpayer shall be liable for such penalty, or

(B)

files a joint return for the taxable year including such month, such individual and the spouse of such individual shall be jointly liable for such penalty.

(c)

Amount of penalty

(1)

In general

The amount of the penalty imposed by this section on any taxpayer for any taxable year with respect to failures described in subsection (b)(1) shall be equal to the lesser of—

(A)

the sum of the monthly penalty amounts determined under paragraph (2) for months in the taxable year during which 1 or more such failures occurred, or

(B)

an amount equal to the national average premium for qualified health plans which have a bronze level of coverage, provide coverage for the applicable family size involved, and are offered through Exchanges for plan years beginning in the calendar year with or within which the taxable year ends.

(2)

Monthly penalty amounts

For purposes of paragraph (1)(A), the monthly penalty amount with respect to any taxpayer for any month during which any failure described in subsection (b)(1) occurred is an amount equal to ¹⁄₁₂ of the greater of the following amounts:

(A)

Flat dollar amount

An amount equal to the lesser of—

(i)

the sum of the applicable dollar amounts for all individuals with respect to whom such failure occurred during such month, or

(ii)

300 percent of the applicable dollar amount (determined without regard to paragraph (3)(C)) for the calendar year with or within which the taxable year ends.

(B)

Percentage of income

An amount equal to the following percentage of the excess of the taxpayer’s household income for the taxable year over the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer for the taxable year:

(i)

1.0 percent for taxable years beginning in 2014.

(ii)

2.0 percent for taxable years beginning in 2015.

(iii)

Zero percent for taxable years beginning after 2015.

(3)

Applicable dollar amount

For purposes of paragraph (1)—

(A)

In general

Except as provided in subparagraphs (B) and (C), the applicable dollar amount is $0.

(B)

Phase in

The applicable dollar amount is $95 for 2014 and $325 for 2015.

(C)

Special rule for individuals under age 18

If an applicable individual has not attained the age of 18 as of the beginning of a month, the applicable dollar amount with respect to such individual for the month shall be equal to one-half of the applicable dollar amount for the calendar year in which the month occurs.

(4)

Terms relating to income and families

For purposes of this section—

(A)

Family size

The family size involved with respect to any taxpayer shall be equal to the number of individuals for whom the taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year.

(B)

Household income

The term “household income” means, with respect to any taxpayer for any taxable year, an amount equal to the sum of—

(i)

the modified adjusted gross income of the taxpayer, plus

(ii)

the aggregate modified adjusted gross incomes of all other individuals who—

(I)

were taken into account in determining the taxpayer’s family size under paragraph (1), and

(II)

were required to file a return of tax imposed by section 1 for the taxable year.

(C)

Modified adjusted gross income

The term “modified adjusted gross income” means adjusted gross income increased by—

(i)

any amount excluded from gross income under section 911, and

(ii)

any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax.

(d)

Applicable individual

For purposes of this section—

(1)

In general

The term “applicable individual” means, with respect to any month, an individual other than an individual described in paragraph (2), (3), or (4).

(2)

Religious exemptions

(A)

Religious conscience exemptions

(i)

In general

Such term shall not include any individual for any month if such individual has in effect an exemption under section 1311(d)(4)(H) of the Patient Protection and Affordable Care Act which certifies that—

(I)

such individual is a member of a recognized religious sect or division thereof which is described in section 1402(g)(1), and is adherent of established tenets or teachings of such sect or division as described in such section; or

(II)

such individual is a member of a religious sect or division thereof which is not described in section 1402(g)(1), who relies solely on a religious method of healing, and for whom the acceptance of medical health services would be inconsistent with the religious beliefs of the individual.

(ii)

Special rules

(I)

Medical health services defined

For purposes of this subparagraph, the term “medical health services” does not include routine dental, vision and hearing services, midwifery services, vaccinations, necessary medical services provided to children, services required by law or by a third party, and such other services as the Secretary of Health and Human Services may provide in implementing section 1311(d)(4)(H) of the Patient Protection and Affordable Care Act.

(II)

Attestation required

Clause (i)(II) shall apply to an individual for months in a taxable year only if the information provided by the individual under section 1411(b)(5)(A) of such Act includes an attestation that the individual has not received medical health services during the preceding taxable year.

(B)

Health care sharing ministry

(i)

In general

Such term shall not include any individual for any month if such individual is a member of a health care sharing ministry for the month.

(ii)

Health care sharing ministry

The term “health care sharing ministry” means an organization—

(I)

which is described in section 501(c)(3) and is exempt from taxation under section 501(a),

(II)

members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed,

(III)

members of which retain membership even after they develop a medical condition,

(IV)

which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999, and

(V)

which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.

(3)

Individuals not lawfully present

Such term shall not include an individual for any month if for the month the individual is not a citizen or national of the United States or an alien lawfully present in the United States.

(4)

Incarcerated individuals

Such term shall not include an individual for any month if for the month the individual is incarcerated, other than incarceration pending the disposition of charges.

(e)

Exemptions

No penalty shall be imposed under subsection (a) with respect to—

(1)

Individuals who cannot afford coverage

(A)

In general

Any applicable individual for any month if the applicable individual’s required contribution (determined on an annual basis) for coverage for the month exceeds 8 percent of such individual’s household income for the taxable year described in section 1412(b)(1)(B) of the Patient Protection and Affordable Care Act. For purposes of applying this subparagraph, the taxpayer’s household income shall be increased by any exclusion from gross income for any portion of the required contribution made through a salary reduction arrangement.

(B)

Required contribution

For purposes of this paragraph, the term “required contribution” means—

(i)

in the case of an individual eligible to purchase minimum essential coverage consisting of coverage through an eligible-employer-sponsored plan, the portion of the annual premium which would be paid by the individual (without regard to whether paid through salary reduction or otherwise) for self-only coverage, or

(ii)

in the case of an individual eligible only to purchase minimum essential coverage described in subsection (f)(1)(C), the annual premium for the lowest cost bronze plan available in the individual market through the Exchange in the State in the rating area in which the individual resides (without regard to whether the individual purchased a qualified health plan through the Exchange), reduced by the amount of the credit allowable under section 36B for the taxable year (determined as if the individual was covered by a qualified health plan offered through the Exchange for the entire taxable year).

(C)

Special rules for individuals related to employees

For purposes of subparagraph (B)(i), if an applicable individual is eligible for minimum essential coverage through an employer by reason of a relationship to an employee, the determination under subparagraph (A) shall be made by reference to 1

 So in original. Probably should be followed by “the”.

required contribution of the employee.

(D)

Indexing

In the case of plan years beginning in any calendar year after 2014, subparagraph (A) shall be applied by substituting for “8 percent” the percentage the Secretary of Health and Human Services determines reflects the excess of the rate of premium growth between the preceding calendar year and 2013 over the rate of income growth for such period.

(2)

Taxpayers with income below filing threshold

Any applicable individual for any month during a calendar year if the individual’s household income for the taxable year described in section 1412(b)(1)(B) of the Patient Protection and Affordable Care Act is less than the amount of gross income specified in section 6012(a)(1) with respect to the taxpayer.

(3)

Members of Indian tribes

Any applicable individual for any month during which the individual is a member of an Indian tribe (as defined in section 45A(c)(6)).

(4)

Months during short coverage gaps

(A)

In general

Any month the last day of which occurred during a period in which the applicable individual was not covered by minimum essential coverage for a continuous period of less than 3 months.

(B)

Special rules

For purposes of applying this paragraph—

(i)

the length of a continuous period shall be determined without regard to the calendar years in which months in such period occur,

(ii)

if a continuous period is greater than the period allowed under subparagraph (A), no exception shall be provided under this paragraph for any month in the period, and

(iii)

if there is more than 1 continuous period described in subparagraph (A) covering months in a calendar year, the exception provided by this paragraph shall only apply to months in the first of such periods.

The Secretary shall prescribe rules for the collection of the penalty imposed by this section in cases where continuous periods include months in more than 1 taxable year.

(5)

Hardships

Any applicable individual who for any month is determined by the Secretary of Health and Human Services under section 1311(d)(4)(H) to have suffered a hardship with respect to the capability to obtain coverage under a qualified health plan.

(f)

Minimum essential coverage

For purposes of this section—

(1)

In general

The term “minimum essential coverage” means any of the following:

(A)

Government sponsored programs

Coverage under—

(i)

the Medicare program under part A of title XVIII of the Social Security Act,

(ii)

the Medicaid program under title XIX of the Social Security Act,

(iii)

the CHIP program under title XXI of the Social Security Act or under a qualified CHIP look-alike program (as defined in section 2107(g) of the Social Security Act),

(iv)

medical coverage under chapter 55 of title 10, United States Code, including coverage under the TRICARE program; 2

 So in original. The semicolon probably should be a comma.

(v)

a health care program under chapter 17 or 18 of title 38, United States Code, as determined by the Secretary of Veterans Affairs, in coordination with the Secretary of Health and Human Services and the Secretary,

(vi)

a health plan under section 2504(e) of title 22, United States Code (relating to Peace Corps volunteers); ² or

(vii)

the Nonappropriated Fund Health Benefits Program of the Department of Defense, established under section 349 of the National Defense Authorization Act for Fiscal Year 1995 (Public Law 103–337; 10 U.S.C. 1587 note).

(B)

Employer-sponsored plan

Coverage under an eligible employer-sponsored plan.

(C)

Plans in the individual market

Coverage under a health plan offered in the individual market within a State.

(D)

Grandfathered health plan

Coverage under a grandfathered health plan.

(E)

Other coverage

Such other health benefits coverage, such as a State health benefits risk pool, as the Secretary of Health and Human Services, in coordination with the Secretary, recognizes for purposes of this subsection.

(2)

Eligible employer-sponsored plan

The term “eligible employer-sponsored plan” means, with respect to any employee, a group health plan or group health insurance coverage offered by an employer to the employee which is—

(A)

a governmental plan (within the meaning of section 2791(d)(8) of the Public Health Service Act), or

(B)

any other plan or coverage offered in the small or large group market within a State.

Such term shall include a grandfathered health plan described in paragraph (1)(D) offered in a group market.

(3)

Excepted benefits not treated as minimum essential coverage

The term “minimum essential coverage” shall not include health insurance coverage which consists of coverage of excepted benefits—

(A)

described in paragraph (1) of subsection (c) of section 2791 of the Public Health Service Act; or

(B)

described in paragraph (2), (3), or (4) of such subsection if the benefits are provided under a separate policy, certificate, or contract of insurance.

(4)

Individuals residing outside United States or residents of territories

Any applicable individual shall be treated as having minimum essential coverage for any month—

(A)

if such month occurs during any period described in subparagraph (A) or (B) of section 911(d)(1) which is applicable to the individual, or

(B)

if such individual is a bona fide resident of any possession of the United States (as determined under section 937(a)) for such month.

(5)

Insurance-related terms

Any term used in this section which is also used in title I of the Patient Protection and Affordable Care Act shall have the same meaning as when used in such title.

(g)

Administration and procedure

(1)

In general

The penalty provided by this section shall be paid upon notice and demand by the Secretary, and except as provided in paragraph (2), shall be assessed and collected in the same manner as an assessable penalty under subchapter B of chapter 68.

(2)

Special rules

Notwithstanding any other provision of law—

(A)

Waiver of criminal penalties

In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure.

(B)

Limitations on liens and levies

The Secretary shall not—

(i)

file notice of lien with respect to any property of a taxpayer by reason of any failure to pay the penalty imposed by this section, or

(ii)

levy on any such property with respect to such failure.

(Added and amended Pub. L. 111–148, title I, § 1501(b), title X, § 10106(b)–(d), Mar. 23, 2010, 124 Stat. 244, 909, 910; Pub. L. 111–152, title I, §§ 1002, 1004(a)(1)(C), (2)(B), Mar. 30, 2010, 124 Stat. 1032, 1034; Pub. L. 111–159, § 2(a), Apr. 26, 2010, 124 Stat. 1123; Pub. L. 111–173, § 1(a), May 27, 2010, 124 Stat. 1215; Pub. L. 115–97, title I, §§ 11002(d)(1)(GG), 11081(a), Dec. 22, 2017, 131 Stat. 2060, 2092; Pub. L. 115–120, div. C, § 3002(g)(2)(A), Jan. 22, 2018, 132 Stat. 35; Pub. L. 115–271, title IV, § 4003(a), Oct. 24, 2018, 132 Stat. 3959.)

cite as: 26 USC 5000A