Minimum Essential Coverage & Who Is Exempt
  1. The Health Insurance Marketplace: Choosing a Category
  2. Essential Health Benefits for All Plans
  3. Qualifying for Lower Premiums and Out-of-Pocket Expenses
  4. Minimum Essential Coverage & Who Is Exempt
  5. Important Dates to Know

Minimum Essential Coverage & Who Is Exempt

If you can afford health insurance and you don’t have coverage in 2016, you may have to pay a fee of 2.5% of your yearly household income or $695 per person ($347.50 per child under 18). This is considerably higher than the fees when the marketplace began in 2014 (1% of your yearly income or $95 per person ($47.50 per child), whichever was higher).

Coverage Minimum

To avoid the fee, you need coverage that qualifies as minimum essential coverage. For 2016, you will be considered covered (and won’t have to pay a fee) if you have any of the following plans:

  • Any employer plan (including COBRA)
  • Any individual insurance plan that you already have
  • Any Marketplace plan
  • Most Medicaid coverage
  • Medicare Part A and Medicare Advantage Plans
  • Peace Corps Volunteer plans
  • The Children’s Health Insurance Program (CHIP)
  • TRICARE (active and retired military, families and survivors)
  • Certain types of veteran's health coverage administered by the Veteran's Administration
  • Coverage under the Non-Appropriated Fund Health Benefit Program
  • Refugee Medical Assistance supported by the Administration for Children and Families
  • Self-funded health coverage offered to students by universities (there are specific rules for which plans are covered)
  • State high risk pools for plan or policy years that begin on or before Dec. 31, 2014

Who's Exempt

If you don’t have coverage in 2016 you may not have to pay the fee if you fall under these exemptions:

  • Are a member of a federally recognized Indian tribe
  • Are insured for at least nine months of the year
  • Don’t have to file a tax return because of low income
  • Have a very low income and you cannot afford coverage (you must complete an application on the Marketplace to determine whether your income qualifies you for an exemption)
  • Participate in a healthcare sharing ministry
  • Are incarcerated
  • Would qualify for Medicaid (under the new income limits) but your state has chosen not to expand eligibility
  • Are a member of a recognized religious sect (such as the Amish and some Mennonite sects) that objects to health insurance

Tip: What determines if you can afford coverage? The IRS determines affordable coverage. Coverage is not considered affordable if it costs more than 8% of your annual household income or if your income falls below income-tax thresholds.

Important Dates to Know

  1. The Health Insurance Marketplace: Choosing a Category
  2. Essential Health Benefits for All Plans
  3. Qualifying for Lower Premiums and Out-of-Pocket Expenses
  4. Minimum Essential Coverage & Who Is Exempt
  5. Important Dates to Know
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