Qualifying Coverage Fees and Exemptions
Most people in the United States must have health coverage or pay a fee. Plans that count as coverage to avoid penalty include:
- Any Marketplace plan or any individual insurance plan you already have
- Any employer plan (including COBRA plans, with or without “grandfathered” status)
- Retiree health plans
- Medicare
- Medicaid
- The Children’s Health Insurance Program (CHIP)
- TRICARE (for current service members and military retirees, their families, and survivors)
- Veterans health care programs (including the Veterans Health Care Program, VA Civilian Health and Medical Program (CHAMPVA), and Spina Bifida Health Care Benefits Program)
- Peace Corps Volunteer plans
- Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014
Other plans may qualify. Ask your health coverage provider.
Exemptions from the fee
Under certain circumstances, individuals won’t have to pay the fee (also known as “the penalty,” “individual shared responsibility payment” or “the individual mandate.” Exemptions from this payment include:
- You’re uninsured for less than three months of the year
- The lowest-priced coverage available to you would cost more than 8 percent of your household income
- You don’t have to file a tax return because your income is too low
- You’re a member of a federally recognized tribe or eligible for services through an Indian Health Services provider
- You’re a member of a recognized health care sharing ministry
- You’re a member of a recognized religious sect with religious objections to insurance, including Social Security and Medicare
- You’re incarcerated (either detained or jailed), and not being held pending disposition of charges
- You’re not lawfully present in the U.S.
- You qualify for a hardship exemption
Hardship exemptions
If any of the following circumstances apply, individuals may qualify for a hardship exemption from the penalty:
- You were homeless
- You were evicted in the past six months or were facing eviction or foreclosure
- You received a shut-off notice from a utility company
- You recently experienced domestic violence
- You recently experienced the death of a close family member
- You experienced a fire, flood or other natural or human-caused disaster that caused substantial damage to your property
- You filed for bankruptcy in the last six months
- You had medical expenses you couldn’t pay in the last 24 months that resulted in substantial debt
- You experienced unexpected increases in necessary expenses due to caring for an ill, disabled or aging family member
- You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to give medical support to the child. In this case, you don’t have the pay the penalty for the child.
- As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower costs on your monthly premiums, or cost-sharing reductions for a time period when you weren’t enrolled in a QHP through the Marketplace
- You were determined ineligible for Medicaid because your state didn’t expand eligibility for Medicaid under the Affordable Care Act
- Your individual insurance plan was cancelled and you believe other Marketplace plans are unaffordable
- You experienced another hardship in obtaining health insurance
Applying for a hardship exemption
Hardship exemptions are usually provided for the month before the hardship, the months of the hardship, and the month after the hardship. However, the Marketplace may provide the exemption for additional months after the hardship, including up to a full calendar year.
- For a hardship exemption based on affordability, the exemption will be granted for the remaining months in the coverage year.
- For people ineligible for Medicaid only because a state hasn’t expanded Medicaid coverage, the hardship exemption will be granted for the whole calendar year.
For people eligible for Indian Health Services, the hardship exemption will be granted on a continuing basis. It may be kept for future years without having to submit another application. This is true as long as there are no changes to your membership in a tribe or eligibility for services from an Indian health care provider.
- Most people must have health coverage or pay a fee. If you don’t have coverage in 2015, you’ll pay a penalty of either 2% of your income, or $325 per adult ($162.50 per child), whichever is higher.
- You’re considered covered under the health care law if you have any job-based plan, any plan you bought yourself, Medicare, Medicaid, CHIP, and many other kinds of coverage. See a full list of plans and programs that meet the health law’s coverage requirement.
Some people qualify for an exemption from the fee based on income or other situations.
To apply for a hardship exemption, visit www.healthcare.gov.
In some cases, you may still be able to get coverage for the rest of 2014 with a Special Enrollment Period (SEP).
This would allow you to sign up for coverage through the end of 2014 even though 2014 Open Enrollment ended March 31, 2014.
Important: Any 2014 plan you enroll in with a Special Enrollment Period ends December 31, 2014. This is true no matter when your 2014 coverage starts.
Getting covered for the rest of 2014
The following Special Enrollment Periods still apply for 2014:
- Having a baby, adopting a child, or placing a child in foster care. If you have a baby, adopt a child, or place a child in foster care any time during 2014, you have up to 60 days after the event to enroll in 2014 coverage. If you enroll within the 60-day period, the new coverage would start on the day of the birth, adoption, or placement in 2014. This is true even if you enroll in the 2014 coverage during 2015.
- If you get married on or before November 30, 2014, you can enroll in 2014 coverage that starts as early as December 1, 2014. If you get married December 1 or later, you should fill out the 2015 application. Your coverage can start as soon as January 1, 2015.
- Losing other health coverage. If you lose a plan that qualifies as minimum essential coverage on or before November 30, 2014 due to job loss, an income increase that makes you no longer eligible for Medicaid, or similar circumstances, you can enroll in a 2014 plan that starts December 1, 2014. In order to get 2014 coverage for the month of December you must select the plan on or before November 30, 2014. If you select a plan after this date, your coverage will start as soon as January 1, 2015. In this case, you should complete the 2015 application.
Important: If you leave your job for any reason and lose your job-based health coverage when you do, you qualify for a Special Enrollment Period. But if you voluntarily drop an individual insurance plan, or drop a job-based plan without leaving your job, you don’t qualify for an SEP.
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