Patient Protection and Affordable Care Act/Title I/Subtitle F/Part I

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Patient Protection and Affordable Care Act
United States Congress
Title I - Quality, Affordable Health Care for All Americans
Subtitle F - Shared Responsibility for Health Care
Part I - Individual Responsibility

PART I--INDIVIDUAL RESPONSIBILITY[edit]

SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.[edit]

(a) Findings- Congress makes the following findings:
(1) IN GENERAL- The individual responsibility requirement provided for in this section (in this subsection referred to as the `requirement') is commercial and economic in nature, and substantially affects interstate commerce, as a result of the effects described in paragraph (2).
(2) EFFECTS ON THE NATIONAL ECONOMY AND INTERSTATE COMMERCE- The effects described in this paragraph are the following:
(A) The requirement regulates activity that is commercial and economic in nature: economic and financial decisions about how and when health care is paid for, and when health insurance is purchased.
(B) Health insurance and health care services are a significant part of the national economy. National health spending is projected to increase from $2,500,000,000,000, or 17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 2019. Private health insurance spending is projected to be $854,000,000,000 in 2009, and pays for medical supplies, drugs, and equipment that are shipped in interstate commerce. Since most health insurance is sold by national or regional health insurance companies, health insurance is sold in interstate commerce and claims payments flow through interstate commerce.
(C) The requirement, together with the other provisions of this Act, will add millions of new consumers to the health insurance market, increasing the supply of, and demand for, health care services. According to the Congressional Budget Office, the requirement will increase the number and share of Americans who are insured.
(D) The requirement achieves near-universal coverage by building upon and strengthening the private employer-based health insurance system, which covers 176,000,000 Americans nationwide. In Massachusetts, a similar requirement has strengthened private employer-based coverage: despite the economic downturn, the number of workers offered employer-based coverage has actually increased.
(E) Half of all personal bankruptcies are caused in part by medical expenses. By significantly increasing health insurance coverage, the requirement, together with the other provisions of this Act, will improve financial security for families.
(F) Under the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act (42 U.S.C. 201 et seq.), and this Act, the Federal Government has a significant role in regulating health insurance which is in interstate commerce.
(G) Under sections 2704 and 2705 of the Public Health Service Act (as added by section 1201 of this Act), if there were no requirement, many individuals would wait to purchase health insurance until they needed care. By significantly increasing health insurance coverage, the requirement, together with the other provisions of this Act, will minimize this adverse selection and broaden the health insurance risk pool to include healthy individuals, which will lower health insurance premiums. The requirement is essential to creating effective health insurance markets in which improved health insurance products that are guaranteed issue and do not exclude coverage of pre-existing conditions can be sold.
(H) Administrative costs for private health insurance, which were $90,000,000,000 in 2006, are 26 to 30 percent of premiums in the current individual and small group markets. By significantly increasing health insurance coverage and the size of purchasing pools, which will increase economies of scale, the requirement, together with the other provisions of this Act, will significantly reduce administrative costs and lower health insurance premiums. The requirement is essential to creating effective health insurance markets that do not require underwriting and eliminate its associated administrative costs.
(3) SUPREME COURT RULING- In United States v. South-Eastern Underwriters Association (322 U.S. 533 (1944)), the Supreme Court of the United States ruled that insurance is interstate commerce subject to Federal regulation.
(b) In General- Subtitle D of the Internal Revenue Code of 1986 is amended by adding at the end the following new chapter:
`CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE
`Sec. 5000A. Requirement to maintain minimum essential coverage.
`SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL COVERAGE.
`(a) Requirement To Maintain Minimum Essential Coverage- An applicable individual shall for each month beginning after 2013 ensure that the individual, and any dependent of the individual who is an applicable individual, is covered under minimum essential coverage for such month.
`(b) Shared Responsibility Payment-
`(1) IN GENERAL- If an applicable individual fails to meet the requirement of subsection (a) for 1 or more months during any calendar year beginning after 2013, then, except as provided in subsection (d), there is hereby imposed a penalty with respect to the individual in the amount determined under subsection (c).
`(2) INCLUSION WITH RETURN- Any penalty imposed by this section with respect to any month shall be included with a taxpayer's return under chapter 1 for the taxable year which includes such month.
`(3) PAYMENT OF PENALTY- If an individual with respect to whom a penalty is imposed by this section for any month--
`(A) is a dependent (as defined in section 152) of another taxpayer for the other taxpayer's taxable year including such month, such other taxpayer shall be liable for such penalty, or
`(B) files a joint return for the taxable year including such month, such individual and the spouse of such individual shall be jointly liable for such penalty.
`(c) Amount of Penalty-
`(1) IN GENERAL- The penalty determined under this subsection for any month with respect to any individual is an amount equal to 1/12 of the applicable dollar amount for the calendar year.
`(2) DOLLAR LIMITATION- The amount of the penalty imposed by this section on any taxpayer for any taxable year with respect to all individuals for whom the taxpayer is liable under subsection (b)(3) shall not exceed an amount equal to 300 percent the applicable dollar amount (determined without regard to paragraph (3)(C)) for the calendar year with or within which the taxable year ends.
`(3) APPLICABLE DOLLAR AMOUNT- For purposes of paragraph (1)--
`(A) IN GENERAL- Except as provided in subparagraphs (B) and (C), the applicable dollar amount is $750.
`(B) PHASE IN- The applicable dollar amount is $95 for 2014 and $350 for 2015.
`(C) SPECIAL RULE FOR INDIVIDUALS UNDER AGE 18- If an applicable individual has not attained the age of 18 as of the beginning of a month, the applicable dollar amount with respect to such individual for the month shall be equal to one-half of the applicable dollar amount for the calendar year in which the month occurs.
`(D) INDEXING OF AMOUNT- In the case of any calendar year beginning after 2016, the applicable dollar amount shall be equal to $750, increased by an amount equal to--
`(i) $750, multiplied by
`(ii) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year, determined by substituting `calendar year 2015' for `calendar year 1992' in subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
`(4) TERMS RELATING TO INCOME AND FAMILIES- For purposes of this section--
`(A) FAMILY SIZE- The family size involved with respect to any taxpayer shall be equal to the number of individuals for whom the taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year.
`(B) HOUSEHOLD INCOME- The term `household income' means, with respect to any taxpayer for any taxable year, an amount equal to the sum of--
`(i) the modified gross income of the taxpayer, plus
`(ii) the aggregate modified gross incomes of all other individuals who--
`(I) were taken into account in determining the taxpayer's family size under paragraph (1), and
`(II) were required to file a return of tax imposed by section 1 for the taxable year.
`(C) MODIFIED GROSS INCOME- The term `modified gross income' means gross income--
`(i) decreased by the amount of any deduction allowable under paragraph (1), (3), (4), or (10) of section 62(a),
`(ii) increased by the amount of interest received or accrued during the taxable year which is exempt from tax imposed by this chapter, and
`(iii) determined without regard to sections 911, 931, and 933.
`(D) POVERTY LINE-
`(i) IN GENERAL- The term `poverty line' has the meaning given that term in section 2110(c)(5) of the Social Security Act (42 U.S.C. 1397jj(c)(5)).
`(ii) POVERTY LINE USED- In the case of any taxable year ending with or within a calendar year, the poverty line used shall be the most recently published poverty line as of the 1st day of such calendar year.
`(d) Applicable Individual- For purposes of this section--
`(1) IN GENERAL- The term `applicable individual' means, with respect to any month, an individual other than an individual described in paragraph (2), (3), or (4).
`(2) RELIGIOUS EXEMPTIONS-
`(A) RELIGIOUS CONSCIENCE EXEMPTION- Such term shall not include any individual for any month if such individual has in effect an exemption under section 1311(d)(4)(H) of the Patient Protection and Affordable Care Act which certifies that such individual is a member of a recognized religious sect or division thereof described in section 1402(g)(1) and an adherent of established tenets or teachings of such sect or division as described in such section.
`(B) HEALTH CARE SHARING MINISTRY-
`(i) IN GENERAL- Such term shall not include any individual for any month if such individual is a member of a health care sharing ministry for the month.
`(ii) HEALTH CARE SHARING MINISTRY- The term `health care sharing ministry' means an organization--
`(I) which is described in section 501(c)(3) and is exempt from taxation under section 501(a),
`(II) members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed,
`(III) members of which retain membership even after they develop a medical condition,
`(IV) which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared continuously and without interruption since at least December 31, 1999, and
`(V) which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.
`(3) INDIVIDUALS NOT LAWFULLY PRESENT- Such term shall not include an individual for any month if for the month the individual is not a citizen or national of the United States or an alien lawfully present in the United States.
`(4) INCARCERATED INDIVIDUALS- Such term shall not include an individual for any month if for the month the individual is incarcerated, other than incarceration pending the disposition of charges.
`(e) Exemptions- No penalty shall be imposed under subsection (a) with respect to--
`(1) INDIVIDUALS WHO CANNOT AFFORD COVERAGE-
`(A) IN GENERAL- Any applicable individual for any month if the applicable individual's required contribution (determined on an annual basis) for coverage for the month exceeds 8 percent of such individual's household income for the taxable year described in section 1412(b)(1)(B) of the Patient Protection and Affordable Care Act. For purposes of applying this subparagraph, the taxpayer's household income shall be increased by any exclusion from gross income for any portion of the required contribution made through a salary reduction arrangement.
`(B) REQUIRED CONTRIBUTION- For purposes of this paragraph, the term `required contribution' means--
`(i) in the case of an individual eligible to purchase minimum essential coverage consisting of coverage through an eligible-employer-sponsored plan, the portion of the annual premium which would be paid by the individual (without regard to whether paid through salary reduction or otherwise) for self-only coverage, or
`(ii) in the case of an individual eligible only to purchase minimum essential coverage described in subsection (f)(1)(C), the annual premium for the lowest cost bronze plan available in the individual market through the Exchange in the State in the rating area in which the individual resides (without regard to whether the individual purchased a qualified health plan through the Exchange), reduced by the amount of the credit allowable under section 36B for the taxable year (determined as if the individual was covered by a qualified health plan offered through the Exchange for the entire taxable year).
`(C) SPECIAL RULES FOR INDIVIDUALS RELATED TO EMPLOYEES- For purposes of subparagraph (B)(i), if an applicable individual is eligible for minimum essential coverage through an employer by reason of a relationship to an employee, the determination shall be made by reference to the affordability of the coverage to the employee.
`(D) INDEXING- In the case of plan years beginning in any calendar year after 2014, subparagraph (A) shall be applied by substituting for `8 percent' the percentage the Secretary of Health and Human Services determines reflects the excess of the rate of premium growth between the preceding calendar year and 2013 over the rate of income growth for such period.
`(2) TAXPAYERS WITH INCOME UNDER 100 PERCENT OF POVERTY LINE- Any applicable individual for any month during a calendar year if the individual's household income for the taxable year described in section 1412(b)(1)(B) of the Patient Protection and Affordable Care Act is less than 100 percent of the poverty line for the size of the family involved (determined in the same manner as under subsection (b)(4)).
`(3) MEMBERS OF INDIAN TRIBES- Any applicable individual for any month during which the individual is a member of an Indian tribe (as defined in section 45A(c)(6)).
`(4) MONTHS DURING SHORT COVERAGE GAPS-
`(A) IN GENERAL- Any month the last day of which occurred during a period in which the applicable individual was not covered by minimum essential coverage for a continuous period of less than 3 months.
`(B) SPECIAL RULES- For purposes of applying this paragraph--
`(i) the length of a continuous period shall be determined without regard to the calendar years in which months in such period occur,
`(ii) if a continuous period is greater than the period allowed under subparagraph (A), no exception shall be provided under this paragraph for any month in the period, and
`(iii) if there is more than 1 continuous period described in subparagraph (A) covering months in a calendar year, the exception provided by this paragraph shall only apply to months in the first of such periods.
The Secretary shall prescribe rules for the collection of the penalty imposed by this section in cases where continuous periods include months in more than 1 taxable year.
`(5) HARDSHIPS- Any applicable individual who for any month is determined by the Secretary of Health and Human Services under section 1311(d)(4)(H) to have suffered a hardship with respect to the capability to obtain coverage under a qualified health plan.
`(f) Minimum Essential Coverage- For purposes of this section--
`(1) IN GENERAL- The term `minimum essential coverage' means any of the following:
`(A) GOVERNMENT SPONSORED PROGRAMS- Coverage under--
`(i) the Medicare program under part A of title XVIII of the Social Security Act,
`(ii) the Medicaid program under title XIX of the Social Security Act,
`(iii) the CHIP program under title XXI of the Social Security Act,
`(iv) the TRICARE for Life program,
`(v) the veteran's health care program under chapter 17 of title 38, United States Code, or
`(vi) a health plan under section 2504(e) of title 22, United States Code (relating to Peace Corps volunteers).
`(B) EMPLOYER-SPONSORED PLAN- Coverage under an eligible employer-sponsored plan.
`(C) PLANS IN THE INDIVIDUAL MARKET- Coverage under a health plan offered in the individual market within a State.
`(D) GRANDFATHERED HEALTH PLAN- Coverage under a grandfathered health plan.
`(E) OTHER COVERAGE- Such other health benefits coverage, such as a State health benefits risk pool, as the Secretary of Health and Human Services, in coordination with the Secretary, recognizes for purposes of this subsection.
`(2) ELIGIBLE EMPLOYER-SPONSORED PLAN- The term `eligible employer-sponsored plan' means, with respect to any employee, a group health plan or group health insurance coverage offered by an employer to the employee which is--
`(A) a governmental plan (within the meaning of section 2791(d)(8) of the Public Health Service Act), or
`(B) any other plan or coverage offered in the small or large group market within a State.
Such term shall include a grandfathered health plan described in paragraph (1)(D) offered in a group market.
`(3) EXCEPTED BENEFITS NOT TREATED AS MINIMUM ESSENTIAL COVERAGE- The term `minimum essential coverage' shall not include health insurance coverage which consists of coverage of excepted benefits--
`(A) described in paragraph (1) of subsection (c) of section 2791 of the Public Health Service Act; or
`(B) described in paragraph (2), (3), or (4) of such subsection if the benefits are provided under a separate policy, certificate, or contract of insurance.
`(4) INDIVIDUALS RESIDING OUTSIDE UNITED STATES OR RESIDENTS OF TERRITORIES- Any applicable individual shall be treated as having minimum essential coverage for any month--
`(A) if such month occurs during any period described in subparagraph (A) or (B) of section 911(d)(1) which is applicable to the individual, or
`(B) if such individual is a bona fide resident of any possession of the United States (as determined under section 937(a)) for such month.
`(5) INSURANCE-RELATED TERMS- Any term used in this section which is also used in title I of the Patient Protection and Affordable Care Act shall have the same meaning as when used in such title.
`(g) Administration and Procedure-
`(1) IN GENERAL- The penalty provided by this section shall be paid upon notice and demand by the Secretary, and except as provided in paragraph (2), shall be assessed and collected in the same manner as an assessable penalty under subchapter B of chapter 68.
`(2) SPECIAL RULES- Notwithstanding any other provision of law--
`(A) WAIVER OF CRIMINAL PENALTIES- In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure.
`(B) LIMITATIONS ON LIENS AND LEVIES- The Secretary shall not--
`(i) file notice of lien with respect to any property of a taxpayer by reason of any failure to pay the penalty imposed by this section, or
`(ii) levy on any such property with respect to such failure.'.
(c) Clerical Amendment- The table of chapters for subtitle D of the Internal Revenue Code of 1986 is amended by inserting after the item relating to chapter 47 the following new item:
`Chapter 48--Maintenance of Minimum Essential Coverage.'.
(d) Effective Date- The amendments made by this section shall apply to taxable years ending after December 31, 2013.

SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.[edit]

(a) In General- Part III of subchapter A of chapter 61 of the Internal Revenue Code of 1986 is amended by inserting after subpart C the following new subpart:
`Subpart D--Information Regarding Health Insurance Coverage
`Sec. 6055. Reporting of health insurance coverage.
`SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.
`(a) In General- Every person who provides minimum essential coverage to an individual during a calendar year shall, at such time as the Secretary may prescribe, make a return described in subsection (b).
`(b) Form and Manner of Return-
`(1) IN GENERAL- A return is described in this subsection if such return--
`(A) is in such form as the Secretary may prescribe, and
`(B) contains--
`(i) the name, address and TIN of the primary insured and the name and TIN of each other individual obtaining coverage under the policy,
`(ii) the dates during which such individual was covered under minimum essential coverage during the calendar year,
`(iii) in the case of minimum essential coverage which consists of health insurance coverage, information concerning--
`(I) whether or not the coverage is a qualified health plan offered through an Exchange established under section 1311 of the Patient Protection and Affordable Care Act, and
`(II) in the case of a qualified health plan, the amount (if any) of any advance payment under section 1412 of the Patient Protection and Affordable Care Act of any cost-sharing reduction under section 1402 of such Act or of any premium tax credit under section 36B with respect to such coverage, and
`(iv) such other information as the Secretary may require.
`(2) INFORMATION RELATING TO EMPLOYER-PROVIDED COVERAGE- If minimum essential coverage provided to an individual under subsection (a) consists of health insurance coverage of a health insurance issuer provided through a group health plan of an employer, a return described in this subsection shall include--
`(A) the name, address, and employer identification number of the employer maintaining the plan,
`(B) the portion of the premium (if any) required to be paid by the employer, and
`(C) if the health insurance coverage is a qualified health plan in the small group market offered through an Exchange, such other information as the Secretary may require for administration of the credit under section 45R (relating to credit for employee health insurance expenses of small employers).
`(c) Statements To Be Furnished to Individuals With Respect to Whom Information Is Reported-
`(1) IN GENERAL- Every person required to make a return under subsection (a) shall furnish to each individual whose name is required to be set forth in such return a written statement showing--
`(A) the name and address of the person required to make such return and the phone number of the information contact for such person, and
`(B) the information required to be shown on the return with respect to such individual.
`(2) TIME FOR FURNISHING STATEMENTS- The written statement required under paragraph (1) shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) was required to be made.
`(d) Coverage Provided by Governmental Units- In the case of coverage provided by any governmental unit or any agency or instrumentality thereof, the officer or employee who enters into the agreement to provide such coverage (or the person appropriately designated for purposes of this section) shall make the returns and statements required by this section.
`(e) Minimum Essential Coverage- For purposes of this section, the term `minimum essential coverage' has the meaning given such term by section 5000A(f).'.
(b) Assessable Penalties-
(1) Subparagraph (B) of section 6724(d)(1) of the Internal Revenue Code of 1986 (relating to definitions) is amended by striking `or' at the end of clause (xxii), by striking `and' at the end of clause (xxiii) and inserting `or', and by inserting after clause (xxiii) the following new clause:
`(xxiv) section 6055 (relating to returns relating to information regarding health insurance coverage), and'.
(2) Paragraph (2) of section 6724(d) of such Code is amended by striking `or' at the end of subparagraph (EE), by striking the period at the end of subparagraph (FF) and inserting `, or' and by inserting after subparagraph (FF) the following new subparagraph:
`(GG) section 6055(c) (relating to statements relating to information regarding health insurance coverage).'.
(c) Notification of Nonenrollment- Not later than June 30 of each year, the Secretary of the Treasury, acting through the Internal Revenue Service and in consultation with the Secretary of Health and Human Services, shall send a notification to each individual who files an individual income tax return and who is not enrolled in minimum essential coverage (as defined in section 5000A of the Internal Revenue Code of 1986). Such notification shall contain information on the services available through the Exchange operating in the State in which such individual resides.
(d) Conforming Amendment- The table of subparts for part III of subchapter A of chapter 61 of such Code is amended by inserting after the item relating to subpart C the following new item:
`subpart d--information regarding health insurance coverage'.
(e) Effective Date- The amendments made by this section shall apply to calendar years beginning after 2013.