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Health Care Reform – Requirement to Get Health Coverage

Authored By: Northwest Justice Project LSC Funded
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5709EN - Starting January 1, 2014, the law requires most people to have “minimum essential coverage.” In general, if you do not have minimum essential coverage, you will have an IRS penalty.

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Introduction

If you do not have health insurance OR your health insurance does not cover the care you need, you might have options under the Affordable Care Act, the federal health reform law. Our publication called Health Care Reform – General Info has more info.

Do I have to have health insurance?

It depends. As of January 1, 2014, the law requires most people to have "minimum essential coverage."  In general, if you do not have minimum essential coverage, you may have to pay an IRS penalty.

What is "minimum essential coverage?"

It is health insurance that is required to cover different types of medical services and to pay for a certain minimum amount of your health care costs.

You already have minimum essential coverage if you have health insurance through one of these plans:

  • coverage through your job

  • Washington Apple Health (Medicaid) or Apple Health for Kids (CHIP)

  • Medicare and Medicare Advantage Plans

  • Government-sponsored coverage

  • Student health coverage

  • Refugee medical assistance

  • Health programs through the Veterans Administration

  • TRICARE

  • Peace Corps Volunteer programs

  • Qualified Health Plans (QHPs) purchased on Healthplanfinder or other individual or group coverage

Most health insurance of the above types is minimum essential coverage. You may NOT have minimum essential coverage if your only health insurance is through one of these plans (or is limited to certain benefits):

  • Coverage for vision only or dental only

  • Cash "insurance" benefits (such as L&I disability cash payments)

If you do not have minimum essential coverage, you will have an IRS tax penalty unless an exemption applies to you, such as: 

  • you do not have to file taxes because your income is below the tax-filing threshold

  • you do not have a lawful immigration status and do not qualify for Medicaid or a Qualified Health Plan

  • you are in jail or prison

  • you are an enrolled member of a federally-recognized Indian Tribe or you are eligible for Indian health care services

  • monthly premiums for the lowest cost coverage available to you would cost more than 8% of your household income

  • you have certain religious objections

  • your income is less than 138% of the Federal Poverty Level AND you lived in a state that did not offer Medicaid Expansion (this exemption does not apply to Washington residents)

  • a financial or other hardship keeps you from getting coverage (the Health Benefit Exchange will decide if your hardship exempts you from coverage)

  • your lapse in coverage lasted less than three months in a row (this exemption is available to you only once per calendar year)

If any of these apply to you, you must file for an exemption from coverage with the IRS. Learn more at www.healthcare.gov/exemptions.

How do I know if I need to get health insurance?

Contact the Health Benefit Exchange, a state-approved organization that administers many of the health reform coverage options, or go online at www.wahealthplanfinder.org. They can tell you if you need to get coverage. They can also help you apply for coverage or an exemption. You can call them at 1-855-923-4633 (1-855-WAFINDER) or email them at customersuppport@wahbexchange.org.

I am required to have health insurance. What happens if I do not?

At the end of each tax year, the IRS checks to see if you were required to have health insurance. If you were, but you did not have it for all or part of the year, the IRS will add a debt to your tax return for that year.  This process is called the "individual responsibility penalty." The debt will cost:

  • in 2016 and 2017: the greater of 2.5% of the household income or $695 for each adult uninsured household member (NOTE: the $695 fee could be adjusted for inflation for 2017)

If you have a child who did not have coverage, the penalty amount is half the adult amount. There are caps on the total penalty amount a family can owe.

How can I apply for coverage?

You can apply for coverage through Healthplanfinder online at www.wahealthplanfinder.org, by phone at 1-855-923-4633 (1-855-WAFINDER), or by using a paper application from Healthplanfinder or your local DSHS office. If you go online, make sure you go to the correct website (www.wahealthplanfinder.org). There are copycat scams at similar sites.

What if I need help applying or understanding my options?

Call an In-Person Assister or an insurance broker. You can find a list of In-Person Assisters at WashingtonLawHelp.org, or go to www.wahealthplanfinder.org and click on the link in the upper right corner to search for a navigator or broker in your area.

 

5709EN

This publication provides general information concerning your rights and responsibilities. It is not intended as a substitute for specific legal advice.
This information is current as of February 2017.

© 2017 Northwest Justice Project — 1-888-201-1014.
(Permission for copying and distribution granted to the Alliance for Equal Justice and to individuals for non-commercial use only.)

Last Review and Update: Mar 05, 2017