Affordable Care Act: Where Things Stand Now

, New York Law Journal


Sidney Kess
Sidney Kess

• Catastrophic—for those under age 31, covers three primary care visits and preventive care, then all other expenses that are out-of-pocket subject to the HSA limits.

Enrollment. Open enrollment on the exchanges (called the individual marketplaces) for 2014 began Oct. 1, 2013, and is set to end on March 31, 2014. Open enrollment for 2015 begins on Nov. 15, 2014, and ends on Jan. 15, 2015.

Individuals with income of more than 400 percent of the federal poverty level (FPL) do not have to purchase coverage through an exchange (they are not eligible for the premium tax credit); they can choose to purchase coverage through an exchange. Alternatively, they can purchase coverage directly from insurance companies (many of which offer online shopping) or through health insurance agents. The 2013 FPL is used to determine eligibility for government assistance with health insurance premiums in 2014. Individuals with income of more than 400 percent of the FPL means individuals with income over $45,960 and a family of four with income over $94,200.

Premium tax credit. This credit is available to individuals whose income is between 133 percent and 400 percent of the FPL and who meet certain eligibility requirements (Code Sec. 36B). This means buying coverage through an exchange or being ineligible for an employer or government plan, filing jointly if married, and not being claimed as a dependent by another taxpayer.

The amount of the credit is keyed to a percentage of household income, which is modified adjusted gross income (adjusted gross income without regard to the foreign earned income exclusion under Code Sec. 911) of all those taken into account in figuring the size of the household. The applicable percentages are:

• Up to 133 percent of FPL—2 percent of household income;

• 133 percent to 150 percent of FPL—3 percent to 4 percent of household income;

• 150 percent to 200 percent of FPL—4 percent to 6.3 percent of household income;

• 200 percent to 250 percent of FPL—6.3 percent to 8.05 percent of household income;

• 250 percent to 300 percent of FPL—8.05 percent to 9.5 percent of household income;

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