CMS issues guidance for ACA individual mandate exemptions

Recent CMS guidance describes qualifications for exemption from the Affordable Care Act’s mandate to have health insurance. Members of federally recognized Native American tribes, people who experience short breaks in coverage, and people who cannot find a plan that meets federal affordability standards can apply for an exemption. The guidance also describes 14 hardship exemptions, such as a recent bankruptcy filing, suffering recent domestic violence, recently experiencing the death of a close family member, experiencing an inability to pay medical expenses in the last two years, or facing higher expenses to provide care for a sick or disabled family member. National Underwriter Life & Health (5/13)

Delaying the Individual Mandate Would Reduce the Deficit

A House bill to delay Obamacare’s individual mandate would save $35 billion dollars, according to the Congressional Office. In July, the House passed H.R. 2668, which would delay the application of the individual health insurance mandate and the employer health insurance mandate for one year. The Congressional Budget Office (CBO) and the Joint Committee on Taxation estimate that enacting H.R. 2668 would reduce federal deficits by roughly $36 billion from 2014 to 2018 and by roughly $35 billion from 2014 to 2023. For more information, visit

Administration Releases New Rules To Implement Health Law’s Individual Mandate

by Mary Agnes Carey

Reprinted with permission from Kaiser Health News (

As congressional Republicans push for a delay in the 2010 health law’s individual mandate, the Obama administration announced final regulations implementing the requirement that most Americans have health insurance coverage by Jan. 1 or pay a fine.

The document from the Treasury Department and the Internal Revenue Service is in addition to regulations the Department of Health and Human Services published in late June.

The regulations specify nine categories of individuals who are exempt from the mandate, including people who can’t afford coverage or taxpayers whose income is so low they don’t have to file a tax return, according to a fact sheet from the agencies. People in jail or who are not in the country lawfully are also exempt, as are individuals who experience a coverage gap of three months or less.

When filing 2014 taxes in 2015, individuals must say on their returns if they have health insurance coverage and, if not, pay a fine. The individual penalty is the greater of $95 or 1% of income, rising to the greater of $695 or 2.5% of income, in 2016. The Congressional Budget Office estimates that less than 2% of Americans who don’t have health insurance will pay the fine.

In July, the Obama Administration delayed for one year a provision in the health law that employers with 50 or more workers offer coverage to employees or pay a fine. Republicans said that if the administration delayed the employer mandate for a year, individuals should also get a reprieve from the health law’s individual mandate set to begin next January. In July, the House of Representatives passed legislation to delay the individual mandate requirement for a year, but the measure is not expected to come to a vote in the Senate.

Tuesday’s announcement from Treasury and the IRS — along with the final individual mandate regulations that HHS issued in June — make it clear that the administration is moving ahead with implementing the individual mandate, which has become one of the law’s most politically explosive elements. House Republicans have tried to repeal or defund the law 40 times on the House floor and more votes are likely this fall.

Supporters of the law and many health care economists say that the requirement that most Americans have coverage or pay a fine is critical to making the law work as intended.

The individual mandate is one of two lynchpins that make the Affordable Care Act work, Washington state Insurance Commissioner Mike Kreidler said in a statement. You simply cannot guarantee everyone coverage — regardless of their health status — without also requiring that everyone participate. The individual mandate guarantees personal responsibility. Without it, there’s nothing to prevent people from only buying health insurance when they need it — which is similar to allowing people to buy homeowners insurance when their house is on fire.

America’s Health Insurance Plans, a trade group representing health insurers, wants the health law’s tax on health insurance plans repealed but supports the individual mandate.

There is broad agreement that requiring health plans to cover everyone, including those with pre-existing conditions, cannot work without an individual mandate, the group said in a statement. By requiring all Americans to get health coverage, the risk pool becomes large enough to account for the sickest Americans, without the adverse effect of skyrocketing premiums.

Treasury: No more ACA delays are planned

Speaking to a House subcommittee, J. Mark Iwry, deputy assistant secretary for retirement and health policy with the Treasury Department, said his department is not looking at any more delays of Affordable Care Act provisions. When asked, he said his department has not analyzed whether it has the ability to postpone the individual mandate. The Hill/Healthwatch blog (7/18)

HHS rule spells out ACA mandate exemptions

HHS has released a final rule that outlines the circumstances for exemption from the Affordable Care Act’s individual mandate. They include non-expansion of Medicaid eligibility, high-cost family coverage through an individual’s employer, a lack of available plans and illegal immigration. Modern Healthcare (subscription required) (6/26)

Last Updated 06/23/2021

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