Breaking down the penalties for opting out of health law

THE BALTIMORE SUNOctober 2, 2013 

Health Overhaul Archetype Small Business

Bartender Sara Tucciarone pours a draft beer for Wheatfields Restaurant owners Tim and Colleen Holmes in Clifton Park, N.Y. The Holmeses were thinking of opening another location but decided against it because they’d then have more than 50 full-time employees.

HANS PENNINK — The Associated Press

Under the Affordable Care Act, everyone who files a federal income tax form is required to have insurance. Most employers also have to offer it. The idea is that for reform to work, everyone needs to enroll so that there is a good mix of healthy and sick people paying into the system.

People can choose not to have insurance and companies can choose not to offer plans. But it will cost them.

Analysts with The Hilltop Institute at the University of Maryland-Baltimore County explain the penalties.

What if an individual chooses not to buy health insurance?

Individuals will be subject to a penalty that accrues for each month he or she goes without coverage. There are exceptions for individuals whose reported income is below the federal tax-filing threshold or who have one of the exemptions specified in federal law, such as religious conscience or hardship.

The federal tax-filing threshold varies based on filing status. Single people younger than 65, for example, don’t have to file if their annual income is below $9,750. (The IRS offers details on its website.)

The penalty will be the greater of:

• A fixed percentage of “applicable income” — defined as the difference between an individual’s household income and the applicable tax-filing threshold. The percentages are: 1 percent for 2014; 2 percent for 2015; and 2.5 percent for 2016 and beyond.

• A fixed annual dollar amount assessed on each taxpayer and dependent. The fixed amounts are: $95 in 2014; $325 in 2015; and $695 in 2016 and beyond.

What happens if a small business chooses not to offer health insurance to its employees?

Businesses with fewer than 50 full-time equivalent employees are not required to provide health insurance and therefore are not subject to any penalties. An employee who works 30 hours or more a week is considered full time.

Employees of small businesses are eligible to purchase health insurance through a state exchange. Depending on the individual’s household income, some people receive premium tax credits to help offset costs.

Small Business Health Options Program Exchanges, created under health reform and operated by the state or federal government, will allow small employers to pool together to make the provision of health insurance less costly.

In addition, tax credits to cover the cost of providing coverage to employees are available to employers with fewer than 25 employees to further incentivize the provision of health coverage.

These small employers may claim this tax credit for two consecutive years.

What happens if a large employer chooses not to offer health insurance to its employees?

The larger U.S. employers, those with 50 or more full-time equivalent employees, will be subject to a penalty if they do not offer health coverage to employees. The penalty for any applicable month is 1/12th x $2,000 x (total number of full-time employees minus 30). The penalty has been delayed until January 2015.

If a company offers coverage but its employees choose to buy a plan from the online state marketplace and use tax subsidies to help pay for it, that company can be penalized only if its health plans are not affordable. If the coverage exceeds more than 9.5 percent of an employee’s household income, it would be considered unaffordable.

The company can also be penalized if it does not pay at least 60 percent of the costs associated with services covered by its health plan. The penalty for any applicable month is 1/12th x $3,000 x (total number of full-time employees minus 30). This penalty also has been delayed until January 2015.

Though the penalty applies only when an employee is receiving financial assistance, the penalty calculation considers all employees, including part-time employees. The large employer would also be subject to a penalty for seasonal employees for the month in which such a worker is full-time and qualifies for premium tax credits or other financial assistance.

What happens if a large employer that is a provider of a self-insured plan, or pays for its employees’ medical costs, chooses not to offer health insurance to its employees?

The above-mentioned large employer requirement is not contingent on the funding of the employer plan. That is, the employer still will be responsible for the penalty whether the plan is self-insured or fully insured.

Under a fully insured plan, the company pays a fixed premium to an insurance carrier.

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