EMPLOYERS:  Employers who have more than 50 full-time equivalent employees must offer those employees benefits that pay for 60% of the minimum essential benefits. If you are in non-compliance, you will incur a penalty of $2,140 per year multiplied by the number of full-time employees, and excludes the first 30 employees. The penalty is increased each year by the growth in insurance premiums. Note you may also incur a penalty when at least one of your employees receives a premium tax credit in the Health Insurance Marketplace (Exchange).

INDIVIDUALS:   The tax penalty and individual mandate has been repealed for 2019, meaning there is no penalty if you did not have health insurance in 2019.

The following information is for 2018 and prior years.  Individuals who failed to obtain qualifying health insurance either directly or through an employer in 2018 and prior years, the tax penalty is 695 for adults. Additionally, the penalty is $347.50 for each child. However, the maximum family penalty is the greater of 2.5% of income, or three times the adult penalty, which is $2,085.  Accordingly, your penalty will be applied on your annual tax return for those years you were not in compliance, again , prior to 2018.

Healthcare reform (the Affordable Care Act – ACA) requires that all individuals have health insurance, either through an individual policy or through their employer or face a potential penalty. Therefore,  individuals can purchase individual insurance coverage on the Individual Market during the annual open enrollment of November 1st through December 15th of each year.  However, if you miss the deadline, you may qualify for special enrollment.

Special Enrollment:

You can still sign up for health insurance after the deadline if you meet any of the following qualifying events:

• change in legal marital status
• a change in the number of dependants
• a change in place of residence and the current carrier is not available
• significant cost or coverage change
• a change in coverage of a spouse or dependant
• a COBRA qualifying event
• legal judgements, decrees and orders
• entitlement to Medicare or Medicaid

The following are new underwriting guidelines of the ACA:

• There is no longer a pre-existing condition clause.  In other words, insurance companies can not increase rates or deny coverage because of a pre-existing condition.
• Your dependents can remain on you policy until they turn 26 years old.
• Insurance companies can not consider gender when setting rates.
• Employer renewals must be based on the same rates as new business.
• The waiting period for employer benefits should not exceed 90 days.

You may be subject to a tax penalty if you do not comply with the “Essental Benefits” of ACA.  Specifically, to be in full compliance with the law, your insurance policy must cover at least 60% of the costs of the following essential benefits.

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Prescription Drugs
• Mental health and Substance Abuse disorder services
• Rehabilitative and habilitative services and devices
• Pediatric services, including oral and vision care
• Preventive and wellness services, and chronic disease management