Individual shared responsibility provision

The individual shared responsibility provision^[1] is the official name of the individual mandate imposed by the Patient Protection and Affordable Care Act in the United States. The mandate requires most individuals and their families to have a certain minimal amount of health insurance, with certain exemptions. Otherwise, they are required to pay the individual shared responsibility payment as a fine. The corresponding payment is the individual shared responsibility payment.^[2] It is one of the many Affordable Care Act tax provisions.

Summary

Starting January 2014, individuals and their families must have at least minimum essential coverage.^[1] Individuals may be exempt from health insurance coverage in some cases:

The minimum amount that they must pay for annual premiums is more than eight percent of their household income.
They have a gap in coverage for less than three consecutive months.
They belong to a group explicitly exempted from participating.
They qualify for an exemption for one of several other reasons, such as a hardship that prevents them from obtaining coverage.

If any other individuals and their families have no health insurance, they will be required to make the shared responsibility payment.^[2]

History

The Patient Protection and Affordable Care Act signed in 2010 imposed a health insurance mandate to take effect in 2014. On June 28, 2012, the Supreme Court of the United States upheld the health insurance mandate as a valid tax, in the case of National Federation of Independent Business v. Sebelius and thus within Congress' taxing power.

Minimum essential coverage

Whether health care coverage qualifies as minimum essential coverage depends largely on the type of coverage it is.^[3] Most coverage that people have is considered to be minimum essential coverage. However, coverage providing only limited benefits does not qualify as minimum essential coverage.^[3]

The following table mentions some of the more common health care coverage situations and whether or not they qualify as minimum essential coverage.^[3]
Coverage Type	Examples	Qualifies as Minimum Essential Coverage?
Employer-sponsored coverage	Group health insurance coverage for employees under a governmental plan, such as the Federal Employees Health Benefit program A self-insured group health plan for employees Retiree coverage	Yes
Individual health coverage	Health insurance purchased directly from an insurance company Health insurance purchased through the Health Insurance Marketplace Health insurance provided through a student health plan	Yes
Coverage under government-sponsored programs	Medicare Part A coverage Medicare Advantage plans Most Medicaid coverage Coverage through a Basic Health Program (BHP) standard health plan	Yes
Coverage that provides limited benefits	Coverage consisting solely of excepted benefits, such as stand-alone dental, vision, accident, or disability insurance Medicaid providing only a single service, for example, providing only family planning services Some TRICARE coverage	No

Coverage exemption

If individuals or anyone in their familes claim an exemption from minimum essential coverage, individuals are not required to make a shared responsibility payment. If individuals have a gross income below the tax return filing threshold for a certain year, they are automatically exempt from the shared responsibility provision for that year.^[4]

Most exemptions are claimed using Form 8965, Health Coverage Exemptions^[5], when a tax return is filed. However, certain exemptions must be granted by the Health Insurance Marketplace in advance, like coverage exemptions for certain hardship situations and for members of certain religious sects.^[4]

The following table shows some types of exemptions available and indicates whether the exemption is granted by the marketplace, claimed on a tax return, or both.^[4]
Exemptions	Granted by Marketplace, Claimed on Tax Return, or either
Coverage is considered unaffordable	Tax Return
Income below the return filing threshold	Tax Return
Citizens living abroad	Tax Return
Nonresidents	Tax Return
Member of Indian Tribe	Either
Member of certain religious sects	Marketplace
General hardship	Marketplace
Resident of a state that did not expand Medicaid	Either

Shared responsibility payment

Individuals without minimum essential coverage, unless they not qualify for exemptions, are required to make the shared responsibility payment. The worksheets located in the instructions^[6] to Form 8965, Health Coverage Exemptions, can be used to figure the shared responsibility payment amount that is due. The annual payment amount is a percentage of the household income in excess of the return filing threshold or a flat dollar amount, whichever is greater.^[7]

References

1 2 "Individual Shared Responsibility Provision". www.irs.gov. Retrieved 2016-02-14.
1 2 "The Individual Shared Responsibility Payment - An Overview". www.irs.gov. Retrieved 2016-02-14.
1 2 3 "Individual Shared Responsibility Provision - Minimum Essential Coverage". www.irs.gov. Retrieved 2016-02-14.
1 2 3 "Individual Shared Responsibility Provision – Exemptions: Claiming or Reporting". www.irs.gov. Retrieved 2016-02-14.
↑ "Form 8965 Health Coverage Exemptions" (PDF). Internal Revenue Service. Retrieved 2016-02-15.
↑ "Instructions for Form 8965" (PDF). Internal Revenue Service. Retrieved 2016-02-15.
↑ "Individual Shared Responsibility Provision – Reporting and Calculating the Payment". www.irs.gov. Retrieved 2016-02-14.

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