Refundable credit for coverage under a qualified health plan
In general
Premium assistance credit amount
For purposes of this section—
In general
Premium assistance amount
The premium assistance amount determined under this subsection with respect to any coverage month is the amount equal to the lesser of—
the monthly premiums for such month for 1 or more qualified health plans offered in the individual market within a State which cover the taxpayer, the taxpayer’s spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an Exchange established by the State under 1311 1
the excess (if any) of—
the adjusted monthly premium for such month for the applicable second lowest cost silver plan with respect to the taxpayer, over
an amount equal to 1/12 of the product of the applicable percentage and the taxpayer’s household income for the taxable year.
Other terms and rules relating to premium assistance amounts
For purposes of paragraph (2)—
Applicable percentage
In general
In the case of household income (expressed as a percent of poverty line) within the following income tier: | The initial premium percentage is— | The final premium percentage is— |
|---|---|---|
Up to 133% | 2.0% | 2.0% |
133% up to 150% | 3.0% | 4.0% |
150% up to 200% | 4.0% | 6.3% |
200% up to 250% | 6.3% | 8.05% |
250% up to 300% | 8.05% | 9.5% |
300% up to 400% | 9.5% | 9.5%. |
Indexing
In general
Additional adjustment
Failsafe
Applicable second lowest cost silver plan
The applicable second lowest cost silver plan with respect to any applicable taxpayer is the second lowest cost silver plan of the individual market in the rating area in which the taxpayer resides which—
is offered through the same Exchange through which the qualified health plans taken into account under paragraph (2)(A) were offered, and
provides—
self-only coverage in the case of an applicable taxpayer—
whose tax for the taxable year is determined under section 1(c) (relating to unmarried individuals other than surviving spouses and heads of households) and who is not allowed a deduction under section 151 for the taxable year with respect to a dependent, or
who is not described in item (aa) but who purchases only self-only coverage, and
family coverage in the case of any other applicable taxpayer.
If a taxpayer files a joint return and no credit is allowed under this section with respect to 1 of the spouses by reason of subsection (e), the taxpayer shall be treated as described in clause (ii)(I) unless a deduction is allowed under section 151 for the taxable year with respect to a dependent other than either spouse and subsection (e) does not apply to the dependent.
Adjusted monthly premium
Additional benefits
If—
a qualified health plan under section 1302(b)(5) of the Patient Protection and Affordable Care Act offers benefits in addition to the essential health benefits required to be provided by the plan, or
a State requires a qualified health plan under section 1311(d)(3)(B) of such Act to cover benefits in addition to the essential health benefits required to be provided by the plan,
the portion of the premium for the plan properly allocable (under rules prescribed by the Secretary of Health and Human Services) to such additional benefits shall not be taken into account in determining either the monthly premium or the adjusted monthly premium under paragraph (2).
Special rule for pediatric dental coverage
Definition and rules relating to applicable taxpayers, coverage months, and qualified health plan
For purposes of this section—
Applicable taxpayer
In general
Special rule for certain individuals lawfully present in the United States
If—
a taxpayer has a household income which is not greater than 100 percent of an amount equal to the poverty line for a family of the size involved, and
the taxpayer is an alien lawfully present in the United States, but is not eligible for the medicaid program under title XIX of the Social Security Act by reason of such alien status,
the taxpayer shall, for purposes of the credit under this section, be treated as an applicable taxpayer with a household income which is equal to 100 percent of the poverty line for a family of the size involved.
Married couples must file joint return
Denial of credit to dependents
Coverage month
For purposes of this subsection—
In general
The term “coverage month” means, with respect to an applicable taxpayer, any month if—
as of the first day of such month the taxpayer, the taxpayer’s spouse, or any dependent of the taxpayer is covered by a qualified health plan described in subsection (b)(2)(A) that was enrolled in through an Exchange established by the State under section 1311 of the Patient Protection and Affordable Care Act, and
the premium for coverage under such plan for such month is paid by the taxpayer (or through advance payment of the credit under subsection (a) under section 1412 of the Patient Protection and Affordable Care Act).
Exception for minimum essential coverage
In general
Minimum essential coverage
Special rule for employer-sponsored minimum essential coverage
For purposes of subparagraph (B)—
Coverage must be affordable
Except as provided in clause (iii), an employee shall not be treated as eligible for minimum essential coverage if such coverage—
consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)), and
the employee’s required contribution (within the meaning of section 5000A(e)(1)(B)) with respect to the plan exceeds 9.5 percent of the applicable taxpayer’s household income.
This clause shall also apply to an individual who is eligible to enroll in the plan by reason of a relationship the individual bears to the employee.
Coverage must provide minimum value
Employee or family must not be covered under employer plan
Indexing
Definitions and other rules
Qualified health plan
Grandfathered health plan
Special rules for qualified small employer health reimbursement arrangements
In general
Denial of double benefit
Affordable coverage
For purposes of subparagraph (A), a qualified small employer health reimbursement arrangement shall be treated as constituting affordable coverage for a month if—
the excess of—
the amount that would be paid by the employee as the premium for such month for self-only coverage under the second lowest cost silver plan offered in the relevant individual health insurance market, over
1⁄12 of the employee’s permitted benefit (as defined in section 9831(d)(3)(C)) under such arrangement, does not exceed—
1⁄12 of 9.5 percent of the employee’s household income.
Qualified small employer health reimbursement arrangement
Coverage for less than entire year
Indexing
Terms relating to income and families
For purposes of this section—
Family size
Household income
Household income
The term “household income” means, with respect to any taxpayer, an amount equal to the sum of—
the modified adjusted gross income of the taxpayer, plus
the aggregate modified adjusted gross incomes of all other individuals who—
were taken into account in determining the taxpayer’s family size under paragraph (1), and
were required to file a return of tax imposed by section 1 for the taxable year.
Modified adjusted gross income
The term “modified adjusted gross income” means adjusted gross income increased by—
any amount excluded from gross income under section 911,
any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax, and
an amount equal to the portion of the taxpayer’s social security benefits (as defined in section 86(d)) which is not included in gross income under section 86 for the taxable year.
Poverty line
In general
Poverty line used
Rules for individuals not lawfully present
In general
If 1 or more individuals for whom a taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year (including the taxpayer or his spouse) are individuals who are not lawfully present—
the aggregate amount of premiums otherwise taken into account under clauses (i) and (ii) of subsection (b)(2)(A) shall be reduced by the portion (if any) of such premiums which is attributable to such individuals, and
for purposes of applying this section, the determination as to what percentage a taxpayer’s household income bears to the poverty level for a family of the size involved shall be made under one of the following methods:
A method under which—
the taxpayer’s family size is determined by not taking such individuals into account, and
the taxpayer’s household income is equal to the product of the taxpayer’s household income (determined without regard to this subsection) and a fraction—
the numerator of which is the poverty line for the taxpayer’s family size determined after application of subclause (I), and
the denominator of which is the poverty line for the taxpayer’s family size determined without regard to subclause (I).
A comparable method reaching the same result as the method under clause (i).
Lawfully present
Secretarial authority
Reconciliation of credit and advance credit
In general
Excess advance payments
In general
Limitation on increase
In general
If the household income (expressed as a percent of poverty line) is: | The applicable dollar amount is: |
|---|---|
Less than 200% | $600 |
At least 200% but less than 300% | $1,500 |
At least 300% but less than 400% | $2,500. |
Indexing of amount
In the case of any calendar year beginning after 2014, each of the dollar amounts in the table contained under clause (i) shall be increased by an amount equal to—
such dollar amount, multiplied by
the cost-of-living adjustment determined under section 1(f)(3) for the calendar year, determined by substituting “calendar year 2013” 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.
Information requirement
Each Exchange (or any person carrying out 1 or more responsibilities of an Exchange under section 1311(f)(3) or 1321(c) of the Patient Protection and Affordable Care Act) shall provide the following information to the Secretary and to the taxpayer with respect to any health plan provided through the Exchange:
The level of coverage described in section 1302(d) of the Patient Protection and Affordable Care Act and the period such coverage was in effect.
The total premium for the coverage without regard to the credit under this section or cost-sharing reductions under section 1402 of such Act.
The aggregate amount of any advance payment of such credit or reductions under section 1412 of such Act.
The name, address, and TIN of the primary insured and the name and TIN of each other individual obtaining coverage under the policy.
Any information provided to the Exchange, including any change of circumstances, necessary to determine eligibility for, and the amount of, such credit.
Information necessary to determine whether a taxpayer has received excess advance payments.
Regulations
The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section, including regulations which provide for—
the coordination of the credit allowed under this section with the program for advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act, and
the application of subsection (f) where the filing status of the taxpayer for a taxable year is different from such status used for determining the advance payment of the credit.
Source
(Added and amended Pub. L. 111–148, title I, § 1401(a), title X, §§ 10105(a)–(c), 10108(h)(1),Notes
Inflation Adjusted Items for Certain Years
References in Text
Amendments
Effective Date of 2016 Amendment
In general.—
Except as otherwise provided in this paragraph, the amendments made by this subsection [amending this section, sections 106, 4980I, 6051, 6652, and 9831 of this title, and section 18081 of Title 42, The Public Health and Welfare] shall apply to years beginning after
Transition relief.—
The relief under Treasury Notice 2015–17 shall be treated as applying to any plan year beginning on or before
Coordination with health insurance premium credit.—
The amendments made by paragraph (3) [amending this section] shall apply to taxable years beginning after
Employee notice.—
In general.—
The amendments made by paragraph (5) [amending section 6652 of this title] shall apply to notices with respect to years beginning after
Transition relief.—
For purposes of section 6652(o) of the Internal Revenue Code of 1986 (as added by this Act), a person shall not be treated as failing to provide a written notice as required by section 9831(d)(4) of such Code if such notice is so provided not later than 90 days after the date of the enactment of this Act [
W–2 reporting.—
The amendments made by paragraph (6)(A) [amending section 6051 of this title] shall apply to calendar years beginning after
Information provided by exchange subsidy applicants.—
In general.—
The amendments made by paragraph (6)(B) [amending section 18081 of Title 42] shall apply to applications for enrollment made after
Verification.—
Verification under section 1411 of the Patient Protection and Affordable Care Act [42 U.S.C. 18081] of information provided under section 1411(b)(3)(B) of such Act shall apply with respect to months beginning after October 2016.
Transitional relief.—
In the case of an application for enrollment under section 1411(b) of the Patient Protection and Affordable Care Act [42 U.S.C. 18081(b)] made before
Effective Date of 2011 Amendment
Effective Date of 2010 Amendment
Effective Date
Substantiation Requirements
No Impact on Social Security Trust Funds
Estimate of secretary.—
The Secretary of the Treasury, or the Secretary’s delegate, shall annually estimate the impact that the amendments made by subsection (a) [amending this section] have on the income and balances of the trust funds established under section 201 of the Social Security Act (42 U.S.C. 401).
Transfer of funds.—
If, under paragraph (1), the Secretary of the Treasury or the Secretary’s delegate estimates that such amendments have a negative impact on the income and balances of such trust funds, the Secretary shall transfer, not less frequently than quarterly, from the general fund an amount sufficient so as to ensure that the income and balances of such trust funds are not reduced as a result of such amendments.”