ELECTRONIC CODE OF FEDERAL REGULATIONS-Falling Below 100 Percent of the FPL
https://www.ecfr.gov/cgi-bin/text-idx?SID=6d09095866384702c28e9a49ba5ee166&node=26:1.0.1.1.1.0.5.53&rgn=div8 ELECTRONIC CODE OF FEDERAL REGULATIONS e-CFR data is current as of July 19, 2018 Title 26 → Chapter I → Subchapter A → Part 1 → §1.36b-2 Title 26: Internal Revenue PART 1—INCOME TAXES §1.36B-2 Eligibility for premium tax credit. (a) In general. An applicable taxpayer (within the meaning of paragraph (b) of this section) is allowed a premium assistance amount only for any month that one or more members of the applicable taxpayer’s family (the applicable taxpayer or the applicable taxpayer’s spouse or dependent)— (1) Is enrolled in one or more qualified health plans through an Exchange; and (2) Is not eligible for minimum essential coverage (within the meaning of paragraph (c) of this section) other than coverage described in section 5000A(f)(1)(C) (relating to coverage in the individual market). (b) Applicable taxpayer—(1) In general. Except as otherwise provided in this paragraph (b), an applicable taxpayer is a taxpayer whose household income is at least 100 percent but not more than 400 percent of the Federal poverty line for the taxpayer’s family size for the taxable year. (2) Married taxpayers must file joint return—(i) In general. Except as provided in paragraph (b)(2)(ii) of this section, a taxpayer who is married (within the meaning of section 7703) at the close of the taxable year is an applicable taxpayer only if the taxpayer and the taxpayer’s spouse file a joint return for the taxable year. (ii) Victims of domestic abuse and abandonment. Except as provided in paragraph (b)(2)(v) of this section, a married taxpayer satisfies the joint filing requirement of paragraph (b)(2)(i) of this section if the taxpayer files a tax return using a filing status of married filing separately and the taxpayer— (A) Is living apart from the taxpayer’s spouse at the time the taxpayer files the tax return; (B) Is unable to file a joint return because the taxpayer is a victim of domestic abuse, as described in paragraph (b)(2)(iii) of this section, or spousal abandonment, as described in paragraph (b)(2)(iv) of this section; and (C) Certifies on the return, in accordance with the relevant instructions, that the taxpayer meets the criteria of this paragraph (b)(2)(ii). (iii) Domestic abuse. For purposes of paragraph (b)(2)(ii) of this section, domestic abuse includes physical, psychological, sexual, or emotional abuse, including efforts to control, isolate, humiliate, and intimidate, or to undermine the victim’s ability to reason independently. All the facts and circumstances are considered in determining whether an individual is abused, including the effects of alcohol or drug abuse by the victim’s spouse. Depending on the facts and circumstances, abuse of the victim’s child or another family member living in the household may constitute abuse of the victim. (iv) Abandonment. For purposes of paragraph (b)(2)(ii) of this section, a taxpayer is a victim of spousal abandonment for a taxable year if, taking into account all facts and circumstances, the taxpayer is unable to locate his or her spouse after reasonable diligence. (v) Three-year rule. Paragraph (b)(2)(ii) of this section does not apply if the taxpayer met the requirements of paragraph (b) (2)(ii) of this section for each of the three preceding taxable years. (3) Dependents. An individual is not an applicable taxpayer if another taxpayer may claim a deduction under section 151 for the individual for a taxable year beginning in the calendar year in which the individual’s taxable year begins. (4) Individuals not lawfully present or incarcerated. An individual who is not lawfully present in the United States or is incarcerated (other than incarceration pending disposition of charges) is not eligible to enroll in a qualified health plan through an Exchange. However, the individual may be an applicable taxpayer if a family member is eligible to enroll in a qualified health plan. See sections 1312(f)(1)(B) and 1312(f)(3) of the Affordable Care Act (42 U.S.C. 18032(f)(1)(B) and (f)(3)) and §1.36B-3(b) (2). (5) Individuals lawfully present. If a taxpayer’s household income is less than 100 percent of the Federal poverty line for the taxpayer’s family size and the taxpayer or a member of the taxpayer’s family is an alien lawfully present in the United States, the taxpayer is treated as an applicable taxpayer if— (i) The lawfully present taxpayer or family member is not eligible for the Medicaid program; and (ii) The taxpayer would be an applicable taxpayer if the taxpayer’s household income for the taxable year was between 100 and 400 percent of the Federal poverty line for the taxpayer’s family size. (6) Special rule for taxpayers with household income below 100 percent of the Federal poverty line for the taxable year—(i) In general. A taxpayer (other than a taxpayer described in paragraph (b)(5) of this section) whose household income for a taxable year is less than 100 percent of the Federal poverty line for the taxpayer’s family size is treated as an applicable taxpayer for the taxable year if— (A) The taxpayer or a family member enrolls in a qualified health plan through an Exchange for one or more months during the taxable year; (B) An Exchange estimates at the time of enrollment that the taxpayer’s household income will be at least 100 percent but not more than 400 percent of the Federal poverty line for the taxable year; (C) Advance credit payments are authorized and paid for one or more months during the taxable year; and (D) The taxpayer would be an applicable taxpayer if the taxpayer’s household income for the taxable year was at least 100 but not more than 400 percent of the Federal poverty line for the taxpayer’s family size. (ii) Exceptions. This paragraph (b)(6) does not apply for an individual who, with intentional or reckless disregard for the facts, provides incorrect information to an Exchange for the year of coverage. A reckless disregard of the facts occurs if the taxpayer makes little or no effort to determine whether the information provided to the Exchange is accurate under circumstances that demonstrate a substantial deviation from the standard of conduct a reasonable person would observe. A disregard of
Consumers Whose Income Drops Below Poverty Get Break On Subsidy Payback
posted from Kaiser Health News https://khn.org/news/consumers-whose-income-drops-below-poverty-get-break-on-subsidy-payback/ written by:columnist Michelle Andrews Right about now, some low-income people who just barely qualified for subsidies on the health insurance marketplace are starting to worry: What if my income for the year ends up below the poverty level? Will I have to pay back the premium tax credits I received? A couple of readers have posed this question in recent weeks. Their concern stems from an unfortunate wrinkle in the health law. Premium tax credits that make coverage on the health insurance exchanges more affordable are available only to people with incomes between 100 and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual this year). People whose income is below the poverty line don’t qualify. This KHN story can be republished for free (details). Their concern stems from an unfortunate wrinkle in the health law. Premium tax credits that make coverage on the health insurance exchanges more affordable are available only to people with incomes between 100 and 400 percent of the federal poverty level ($11,490 to $45,960 for an individual this year). People whose income is below the poverty line don’t qualify. Now, people who didn’t qualify for Medicaid and whose estimated income is coming up short of the poverty level are worried they’ll have to repay thousands of dollars in premium tax credits. One reader wrote: “What is going to happen? Will he have to pay back all of the money that he received for the tax credit since he no longer qualifies?” The short answer is no. No repayment will be required. According to a Treasury Department rule, if the insurance marketplace estimates that someone’s income will be between 100 and 400 percent of poverty and it turns out that his income for the year is below the poverty threshold, the individual won’t be on the hook for any premium tax credits he received. Since the marketplace always makes the eligibility determination for tax credits, no one whose income ends up below the poverty level should have to repay them, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities. The same isn’t true for people whose income is above the poverty line, however. Above that threshold, people who received too much in premium tax credits will be responsible for repaying those amounts up to a cap, based on their income. And above 400 percent of the poverty level, they’re responsible for repaying the entire amount. Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.
Tax Credits Still Unchanged
Ashley Semanskee, Gary Claxton, and Larry Levitt Follow @larry_levitt on Twitter original blog post (https://www.kff.org/health-reform/issue-brief/how-premiums-are-changing-in-2018/) Updated: Nov 29, 2017 | Published: Nov 14, 2017 The premiums for 2018 Marketplace plans were recently released to give consumers a chance to look at their plan options before open enrollment begins on November 1. Premiums are rising significantly in many counties across the country, in part due to the decision of the Trump Administration to cease payments to insurers for cost-sharing reductions. Insurer participation also declined in many areas, leaving more counties with only one insurer, which likely contributed to the high rate of premium growth. The map below illustrates how premiums changed for 2018 by looking at the change in the lowest-cost bronze, silver and gold plans by county. Results are shown for a 40-year-old paying the full premium and for a 40-year old with an income of $20,000 (166% of poverty), $25,000 (207% of poverty), $30,000 (249% of poverty), $35,000 (290% of poverty), and $40,000 (332% of poverty), who would be eligible for a premium tax credit. Percent Change in Lowest-Cost Metal Plan Before and After Tax Credit, 2017-2018 https://publicstatic.tableausoftware.com/vizql/v_105001803220826/javascripts/ViewerBootstrap.js Nationally, the unsubsidized premium for the lowest-cost bronze plan is increasing an average of 17% between 2017 and 2018, the lowest-cost silver plan is increasing an average of 32%, and the lowest-cost gold plan is increasing an average of 18% (Table 1). These average increases are weighted by the number of plan selections by county in 2017 (see Methods). Premiums for silver plans are rising much more than those for bronze or gold plans because in many states insurers loaded the cost from the termination of the cost-sharing reduction payments entirely on the silver tier. For consumers who receive premium tax credits, the amounts that they will have to pay will often be lower in 2018 (Table 2). The particularly large increase in premiums for silver plans means that tax-credit-eligible Marketplace enrollees will see much higher premium tax credits (which are calculated based on the second-lowest-cost silver plan in each area). These large credits make gold plans more easily attainable and make bronze plans much cheaper (or even available at no additional premium). In fact, after these increases, the lowest-cost gold premium is lower than the lowest-cost silver premium in 478 counties. For example, a 40-year-old individual making $35,000 (249% of poverty) and eligible for a tax credit will on average pay 36% less in 2018 for their share of the premium for the lowest-cost bronze plan, 6% less for the lowest-cost silver plan, and 12% less for the lowest-cost gold plan. The savings are greater for subsidized enrollees with lower incomes and less for those with higher incomes (Table 2). The premiums for bronze plans may be particularly attractive to many people eligible for premium tax credits. For example, the tax credit for a 40-year-old individual making $25,000 covers the full cost of the premium for the lowest-cost bronze plan in 1,679 counties (Table 3). Table 1: Average Change in the Lowest-Cost Premium by Metal Level Before Tax Credit, 2017-2018 for a 40-year-old % Change in Lowest Cost Bronze Premium +17% % Change in Lowest Cost Silver Premium +32% % Change in Lowest Cost Gold Premium +18% SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings. Table 2: Average Change in the Lowest-Cost Premium by Metal Level After Tax Credit, 2017-2018 40-year-old with $20,000 income (166% of poverty) % Change in Lowest Cost Bronze Premium -85% % Change in Lowest Cost Silver Premium -14% % Change in Lowest Cost Gold Premium -26% 40-year-old with $25,000 income (207% of poverty) % Change in Lowest Cost Bronze Premium -69% % Change in Lowest Cost Silver Premium -10% % Change in Lowest Cost Gold Premium -20% 40-year-old with $30,000 income (249% of poverty) % Change in Lowest Cost Bronze Premium -50% % Change in Lowest Cost Silver Premium -8% % Change in Lowest Cost Gold Premium -16% 40-year-old with $35,000 income (290% of poverty) % Change in Lowest Cost Bronze Premium -36% % Change in Lowest Cost Silver Premium -6% % Change in Lowest Cost Gold Premium -12% 40-year-old with $40,000 income (332% of poverty) % Change in Lowest Cost Bronze Premium -24% % Change in Lowest Cost Silver Premium 1% % Change in Lowest Cost Gold Premium -6% SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings. Table 3: Number of Counties Where an Individual’s Tax Credit Covers the Full Premium of the Lowest-Cost Bronze Plan in 2018, for a 40-year-old Example Age and Income Number of counties where the tax credit covers the full premium for the lowest-cost bronze plan 40-year-old with $20,000 income (166% of poverty 2434 40-year-old with $25,000 income (207% of poverty) 1679 40-year-old with $30,000 income (248% of poverty) 488 40-year-old with $35,000 income (290% of poverty) 169 40-year old with $40,000 income (332% of poverty) 104 SOURCE: Kaiser Family Foundation analysis of premium data from Healthcare.gov and review of state rate filings. The map below shows where an individual’s tax credit covers the full premium of the lowest-cost bronze plan for a 40-year-old with an income of $20,000 (166% of poverty), $25,000 (207% of poverty), $30,000 (249% of poverty), $35,000 (290% of poverty), and $40,000 (332% of poverty). Counties Where the Lowest-Cost Bronze Plan Premium Costs Zero Dollars After the Tax Credit in 2018 https://publicstatic.tableausoftware.com/vizql/v_105001803220826/javascripts/built-dojo/dojo/dojo.js The map below shows counties where the unsubsidized premium for the lowest-cost gold plan has a lower or comparable premium to the lowest-cost silver plan in 2018. Counties Where the Lowest-Cost Gold Plan Costs Less than the Lowest-Cost Silver Plan https://publicstatic.tableausoftware.com/vizql/v_105001803220826/javascripts/built-dojo/dojo/dojo.js Discussion The differences in premium changes across plan types and the peculiar effect these differences have on plan costs for both unsubsidized and subsidized enrollees makes it important that consumers shop around and carefully consider their options. Although CMS will no longer be paying insurers for reducing the cost sharing for lower-income enrollees, insurers remain obliged to provide the reduced cost sharing policies
No, Obamacare Hasn’t Jacked Up Your Company’s Insurance Rates
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We have a shorter window than ever before to help individuals enroll. The exciting thing is, that even though there’s been some turmoil in this law, its subsidies, and its cost sharing reductions (mainly by individuals unaffected or lacking basic understanding) there were protections built in to help ensure the laws survival. We’re seeing that rates this year are closer to ZERO premiums for many more individuals than before. Please call us to help guide you through the questions, concerns and challenges. Jesus Bustillos
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