[Federal Register Volume 76, Number 159 (Wednesday, August 17, 2011)]
[Proposed Rules]
[Pages 50931-50949]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2011-20728]
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DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 1
[REG-131491-10]
RIN 1545-BJ82
Health Insurance Premium Tax Credit
AGENCY: Internal Revenue Service (IRS), Treasury.
ACTION: Notice of proposed rulemaking and notice of public hearing.
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SUMMARY: This document contains proposed regulations relating to the
health insurance premium tax credit enacted by the Patient Protection
and Affordable Care Act and the Health Care and Education
Reconciliation Act of 2010, as amended by the Medicare and Medicaid
Extenders Act of 2010, the Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011, and the
Department of Defense and Full-Year Continuing Appropriations Act,
2011. These proposed regulations provide guidance to individuals who
enroll in qualified health plans through Affordable Insurance Exchanges
and claim the premium tax credit, and to Exchanges that make qualified
health plans available to individuals and
[[Page 50932]]
employers. This document also provides notice of a public hearing on
these proposed regulations.
DATES: Written (including electronic) comments must be received by
October 31, 2011. Outlines of topics to be discussed at the public
hearing scheduled for November 17, 2011, at 10 a.m. must be received by
November 10, 2011.
ADDRESSES: Send submissions to: CC:PA:LPD:PR (REG-131491-10), Room
5203, Internal Revenue Service, PO Box 7604, Ben Franklin Station,
Washington, DC 20044. Submissions may be hand-delivered Monday through
Friday between the hours of 8 a.m. and 4 p.m. to CC:PA:LPD:PR (REG-
131491-10), Courier's Desk, Internal Revenue Service, 1111 Constitution
Avenue, NW., Washington, DC, or sent electronically via the Federal
eRulemaking Portal at http://www.regulations.gov (IRS REG-131491-10).
The public hearing will be held in the IRS Auditorium, Internal Revenue
Building, 1111 Constitution Avenue, NW., Washington, DC.
FOR FURTHER INFORMATION CONTACT: Concerning the proposed regulations,
Shareen S. Pflanz, (202) 622-4920, or Frank W. Dunham III, (202) 622-
4960; concerning the submission of comments, the public hearing, and to
be placed on the building access list to attend the public hearing,
Funmi Taylor, (202) 622-7180 (not toll-free calls).
SUPPLEMENTARY INFORMATION:
Paperwork Reduction Act
The collection of information contained in this notice of proposed
rulemaking has been submitted to the Office of Management and Budget in
accordance with the Paperwork Reduction Act of 1995 (44 U.S.C.
3507(d)). Comments on the collection of information should be sent to
the Office of Management and Budget, Attn: Desk Officer for the
Department of the Treasury, Office of Information and Regulatory
Affairs, Washington, DC 20503, with copies to the Internal Revenue
Service, Attn: IRS Reports Clearance Officer, SE:W:CAR:MP:T:T:SP,
Washington, DC 20224. Comments on the collection of information should
be received by October 17, 2011. Comments are specifically requested
concerning:
Whether the proposed collection of information is necessary for the
proper performance of the functions of the IRS, including whether the
information will have practical utility;
How the quality, utility, and clarity of the information to be
collected may be enhanced;
How the burden of complying with the proposed collection of
information may be minimized, including through the application of
automated collection techniques or other forms of information
technology; and
Estimates of capital or start-up costs and costs of operation,
maintenance, and purchase of services to provide information.
The collection of information in these proposed regulations is in
Sec. 1.36B-5. The collection of information is necessary to properly
reconcile the amount of the premium tax credit with advance credit
payments made under section 1412 of the Patient Protection and
Affordable Care Act (42 U.S.C. 18082). The collection of information is
required to comply with the provisions of section 36B(f)(3) of the
Internal Revenue Code (Code). The likely respondents are Affordable
Insurance Exchanges established under section 1311 or 1321 of the
Patient Protection and Affordable Care Act (42 U.S.C. 13031 or 42
U.S.C. 18041).
The burden for the collection of information contained in proposed
regulation Sec. 1.36B-5 will be reflected in the burden on a form that
the IRS will create to request the information in the proposed
regulation.
An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a valid
control number assigned by the Office of Management and Budget.
Background
Beginning in 2014, under the Patient Protection and Affordable Care
Act, Public Law 111-148 (124 Stat. 119 (2010)), and the Health Care and
Education Reconciliation Act of 2010, Public Law 111-152 (124 Stat.
1029 (2010)) (collectively, the Affordable Care Act), individuals and
small businesses will be able to purchase private health insurance
through State-based competitive marketplaces called Affordable
Insurance Exchanges (Exchanges). Exchanges will offer Americans
competition and choice. Insurance companies will compete for business
on a level playing field, driving down costs. Consumers will have a
choice of health plans to fit their needs and Exchanges will give
individuals and small businesses the same purchasing power as big
businesses. The Departments of Health and Human Services and Treasury
are working in close coordination to release guidance related to
Exchanges, in several phases. The first in this series was a Request
for Comment relating to Exchanges, published in the Federal Register on
August 3, 2010 (75 FR 45584). Second, Initial Guidance to States on
Exchanges was issued on November 18, 2010. Third, proposed regulations
on the application, review, and reporting process for waivers for State
innovation was published in the Federal Register on March 14, 2011 (76
FR 13553). Fourth, two proposed regulations were published in the
Federal Register on July 15, 2011 (76 FR 41866 and 76 FR 41930) to
implement components of the Exchange and health insurance premium
stabilization policies in the Affordable Care Act. Fifth, three
proposed regulations, including this one, are being published in the
Federal Register on August 17, 2011 to provide guidance on the
eligibility determination process related to enrollment in a qualified
health plan or insurance affordability program; on Medicaid, the
Children's Health Insurance Program (CHIP), and other State health
coverage programs; and these proposed regulations on the premium tax
credit.
Section 1401 of the Affordable Care Act amended the Code to add
section 36B, allowing a refundable premium tax credit to help
individuals and families afford health insurance coverage. Section 36B
was subsequently amended by the Medicare and Medicaid Extenders Act of
2010, Public Law 111-309 (124 Stat. 3285 (2010)); the Comprehensive
1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments
Act of 2011, Public Law 112-9 (125 Stat. 36 (2011)); and the Department
of Defense and Full-Year Continuing Appropriations Act, 2011, Public
Law 112-10 (125 Stat. 38 (2011)). The section 36B credit is designed to
make a qualified health plan affordable by reducing a taxpayer's out-
of-pocket premium cost.
Under section 1411 of the Affordable Care Act (42 U.S.C. 18081), an
Exchange makes an advance determination of credit eligibility for
individuals enrolling in coverage through the Exchange and seeking
financial assistance. Using information available at the time of
enrollment, the Exchange determines (1) whether the individual meets
the income and other requirements for advance credit payments, and (2)
the amount of the advance payments. Advance payments are made monthly
under section 1412 of the Affordable Care Act (42 U.S.C. 18082) to the
issuer of the qualified health plan in which the individual enrolls.
[[Page 50933]]
Eligibility
To be eligible for a premium tax credit, an individual must be an
applicable taxpayer. Under section 36B(c)(1), an applicable taxpayer is
a taxpayer (1) With household income for the taxable year between 100
percent and 400 percent of the federal poverty line (FPL) for the
taxpayer's family size, (2) who may not be claimed as a dependent by
another taxpayer, and (3) who files a joint return if married.
Section 36B(c)(1)(B) provides that a taxpayer who is an alien
lawfully present in the United States, whose household income is 100
percent of the FPL or less, and who is not eligible for Medicaid,
nonetheless is treated as an applicable taxpayer. Under section
36B(e)(2), an individual is lawfully present if the individual is, and
is reasonably expected to be for the entire period of enrollment for
which the credit is claimed, a U.S. citizen or national or an alien
lawfully present in the United States.
Under section 36B(d)(1), a taxpayer's family consists of the
individuals for whom the taxpayer claims a personal exemption deduction
under section 151 for the taxable year. Taxpayers may claim a personal
exemption deduction for themselves, a spouse, and each of their
dependents. Section 152 provides that a taxpayer's dependent may be a
qualifying child or qualifying relative, including an unrelated
individual who lives with the taxpayer. Family size is equal to the
number of individuals in the taxpayer's family.
Section 36B(d)(2) defines household income as the modified adjusted
gross income of all individuals included in family size who are
required to file an income tax return. Modified adjusted gross income
means adjusted gross income (within the meaning of section 62)
increased by amounts excluded from gross income under section 911 and
tax-exempt interest a taxpayer receives or accrues during the taxable
year.
Under section 36B(b)(1), a taxpayer's premium assistance credit
amount is the sum of the premium assistance amounts for all coverage
months in the taxable year for individuals in the taxpayer's family.
Section 36B(c)(2)(A) provides that a coverage month is any month for
which the taxpayer or any family member is covered by a qualified
health plan enrolled in through an Exchange and the premium is paid by
the taxpayer or through an advance credit payment.
Under section 36B(c)(2)(B), a coverage month for an individual does
not include a month in which the individual is eligible for minimum
essential coverage, as defined in section 5000A(f), other than coverage
offered in the individual market. Minimum essential coverage may be
government-sponsored coverage such as Medicare, Medicaid, CHIP,
TRICARE, and veterans' health care under Title 38 U.S.C. Certain
employer-sponsored plans also may be minimum essential coverage. In
general, under section 36B(c)(2)(C), an individual is eligible for
employer-sponsored minimum essential coverage only if the employee's
share of the premiums is affordable and the coverage provides minimum
value. However, under section 36B(c)(2)(C)(iii), an individual is
treated as eligible for employer-sponsored minimum essential coverage
if the individual actually enrolls in an eligible employer-sponsored
plan, even if the coverage does not meet the affordability and minimum
value requirements.
Under section 5000A(f)(1)(E), the Department of Health and Human
Services, in coordination with the Treasury Department, may designate
other health benefits coverage as minimum essential coverage.
Regulations under section 5000A are expected to provide additional
guidance on minimum essential coverage.
Credit Computation
Section 36B(b)(1) provides that the premium assistance credit
amount is the sum of the premium assistance amounts for all coverage
months in the taxable year for individuals in the taxpayer's family.
The premium assistance amount for a coverage month is the lesser of (1)
the premiums for the month for one or more qualified health plans that
cover a taxpayer or family member, or (2) the excess of the adjusted
monthly premium for the second lowest cost silver plan (as described in
section 1302(d)(1)(B) of the Affordable Care Act (42 U.S.C.
18022(d)(1)(B))) (the benchmark plan) that applies to the taxpayer over
\1/12\ of the product of the taxpayer's household income and the
applicable percentage for the taxable year. The adjusted monthly
premium, in general, is the premium an insurer would charge for the
plan adjusted only for the ages of the covered individuals.
Therefore, the monthly premium assistance amount is the lesser of
the premium for the qualified health plan in which a taxpayer or family
member enrolls, or the excess of the premium for the benchmark plan
over the applicable percentage of the taxpayer's household income. In
general, this percentage of the taxpayer's household income represents
the amount of the taxpayer's required out-of-pocket contribution to the
premium cost if the taxpayer purchases the benchmark plan. The
remainder of the premium for the benchmark plan is the premium
assistance amount.
A taxpayer's applicable percentage increases as the taxpayer's
household income as a percentage of the FPL (FPL percentage) for the
taxpayer's family size increases. For 2014, the applicable percentage
is 2 percent for taxpayers with household income up to 133 percent of
the FPL and increases from 3 percent to 9.5 percent for taxpayers with
household incomes between 133 percent and 400 percent of the FPL. The
applicable percentages may be adjusted after 2014.
Taxpayers must pay the difference between the premium assistance
amount and the premium for the plan they choose. The amount of a
taxpayer's credit is limited to the amount of actual premiums for the
taxable year.
Individuals not lawfully present are not eligible to enroll in a
qualified health plan through an Exchange. Accordingly, section
36B(e)(1)(A) provides that, for a household with at least one
individual not lawfully present, the portion (if any) of the premium
attributable to that individual is not included in determining the
taxpayer's credit. Section 36B(e)(1)(B) provides that the family size
for computing the FPL percentage for a family with at least one
unlawfully present individual is determined by excluding the unlawfully
present individual. Household income for computing the FPL percentage
and determining the applicable percentage is the product of the
taxpayer's household income (determined without regard to section
36B(e)) and a fraction, the numerator of which is the FPL for the
taxpayer's family size excluding individuals who are not lawfully
present, and the denominator of which is the FPL for the taxpayer's
family size including individuals who are not lawfully present.
Reconciliation
A taxpayer must reconcile the actual credit for the taxable year
computed on the taxpayer's tax return with the amount of advance
payments. If a taxpayer's credit amount exceeds the amount of the
taxpayer's advance payments for the taxable year, the taxpayer may
receive the excess as an income tax refund. If a taxpayer's advance
payments exceed the taxpayer's credit amount, the taxpayer owes the
excess as an additional income tax liability. However, section
36B(f)(2)(B) places a graduated set of caps on the additional tax
liability for taxpayers with household income under 400 percent of the
FPL. The repayment
[[Page 50934]]
limitation amounts range from $600 to $2,500 (one-half that amount for
single taxpayers) depending on FPL, and are adjusted to reflect changes
in the cost of living beginning in 2015.
Section 36B(g) directs the Secretary of the Treasury to issue
regulations that provide for coordinating the premium tax credit with
the program for advance payments and for reconciling the credit and
advance payments when the taxpayer's filing status changes during the
taxable year.
Information Reporting
Section 36B(f)(3) directs an Exchange to report to the IRS and
taxpayers certain information relating to health plans provided through
the Exchange, including the amount of any advance credit payments.
Explanation of Provisions
1. Eligibility for the Premium Tax Credit
The proposed regulations provide that a taxpayer is eligible for
the credit for a taxable year if the taxpayer is an applicable taxpayer
and the taxpayer or a member of the taxpayer's family (1) is enrolled
in one or more qualified health plans through an Exchange established
under section 1311 or 1321 of the Affordable Care Act (42 U.S.C. 13031
or 42 U.S.C. 18041) and (2) is not eligible for minimum essential
coverage other than coverage in the individual market.
a. Applicable Taxpayer
i. Lawfully Present Aliens
In general, to be an applicable taxpayer, a taxpayer must have
household income that is at least 100 percent but not more than 400
percent of the FPL. Under section 36B(c)(1)(B), a lawfully present
alien with household income under 100 percent of the FPL and not
eligible for Medicaid is treated as having household income of 100
percent of the FPL for purposes of qualifying as an applicable
taxpayer. The proposed regulations provide that premium assistance
amounts for these taxpayers are computed based on actual household
income. The proposed regulations define lawfully present by reference
to 45 CFR 152.2, which determines lawful presence for purposes of the
Pre-Existing Condition Insurance Plan Program.
ii. Taxpayers With Household Income Under 100 Percent of the FPL
The proposed regulations clarify the treatment of a taxpayer who
receives advance credit payments but has household income below 100
percent of the FPL for the taxable year.
Taxpayers with household incomes below 100 percent of the FPL
(other than lawfully present aliens) are not eligible for the premium
tax credit because they are eligible to receive assistance through
Medicaid. However, an Exchange may approve a taxpayer for advance
credit payments based on projecting a level of household income for the
taxable year that makes the taxpayer ineligible for Medicaid. If,
contrary to that projection, the taxpayer's actual household income for
the taxable year is under 100 percent of the FPL (for example, because
the taxpayer experiences a change in circumstances, such as a job loss,
during the year), the taxpayer would not be an applicable taxpayer, and
would not be eligible for the credit under the general rule.
Accordingly, the proposed regulations provide a special rule treating a
taxpayer with household income below 100 percent of the FPL as an
applicable taxpayer if, when a taxpayer enrolls in a qualified health
plan, an Exchange projects that household income for the taxpayer will
be between 100 and 400 percent of the FPL for the taxable year and
approves advance credit payments. Premium assistance amounts for these
taxpayers also are computed based on actual household income and not a
deemed household income that equals 100 percent of the FPL.
iii. Individuals Who Are Incarcerated or Not Lawfully Present
Under section 1312(f) of the Affordable Care Act, individuals who
are incarcerated (other than pending disposition of charges) or not
lawfully present in the United States may not enroll in a qualified
health plan through an Exchange. However, these individuals may have
family members who are eligible for Exchange coverage. Accordingly, the
proposed regulations provide that an individual who is not lawfully
present in the United States or is incarcerated, although not eligible
to enroll in a qualified health plan, may be an applicable taxpayer if
a family member is eligible to and does enroll in a qualified health
plan.
b. Minimum Essential Coverage
i. Government-Sponsored Coverage
Under the proposed regulations, an individual generally is eligible
for government-sponsored minimum essential coverage for any month that
the individual meets the requirements for coverage under a government-
sponsored program described in section 5000A(f)(1)(A). However, for
purposes of the premium tax credit, an individual is eligible for
minimum essential coverage under a veterans' health care program only
if the individual is enrolled in a veteran's health care program
identified as minimum essential coverage in regulations issued under
section 5000A. The Commissioner may define eligibility for specific
government-sponsored programs further in published guidance of general
applicability, see Sec. 601.601(d)(2) of this chapter. For example, it
is expected that future guidance will provide that a person is eligible
for Medicaid on the basis of being blind or disabled or needing long-
term care services only when a State Medicaid agency or the Social
Security Administration, as appropriate, determines that the individual
is blind or disabled or requires long-term care services.
In general, an individual is treated as eligible for a government-
sponsored program on the first day of the first full month in which the
individual may receive benefits. Thus, taxpayers would not lose
eligibility for the credit for a month in which the taxpayer or a
family member is technically eligible for a government program but
cannot yet receive benefits due to, for example, the need for
administrative processing. However, an individual who fails to complete
the requirements to obtain coverage available under a government-
sponsored program (other than coverage under the veteran's health care
program) reasonably promptly is treated as eligible for the coverage on
the first day of the second calendar month following the event that
establishes eligibility (such as reaching age 65 for Medicare).
An individual receiving advance credit payments may apply and be
approved for government-sponsored minimum essential coverage such as
Medicaid that, after approval, is effective retroactively (overlapping
some advance payment coverage months). The proposed regulations provide
that an individual in this situation is treated as eligible for minimum
essential coverage no sooner than the first day of the first calendar
month after the approval.
Comments are requested on whether rules should provide additional
flexibility if operational challenges prevent timely transition from
coverage under a qualified health plan to coverage under a government-
sponsored program.
A taxpayer whom an Exchange has determined to be ineligible for
Medicaid, CHIP, or a similar program at the time of enrollment may end
up with household income for the taxable year within the eligibility
criteria for these
[[Page 50935]]
programs. Therefore, the proposed regulations provide that an
individual is treated as not eligible for Medicaid, CHIP, or a similar
program for the months of coverage under a qualified health plan if an
Exchange determines that the individual is not eligible when the
individual enrolls. If the individual subsequently enrolls in Medicaid,
CHIP, or a similar program, however, the full months of enrollment in
the government-sponsored coverage are not coverage months.
ii. Employer-Sponsored Coverage
A. In General
Section 5000A(f)(1)(B) provides that minimum essential coverage
includes coverage under an eligible employer-sponsored plan. Under
section 5000A(f)(2), an eligible employer-sponsored plan is a group
health plan or group health insurance coverage offered by an employer
to an employee that is a governmental plan (within the meaning of
section 2791(d)(8) of the Public Health Service Act (42 U.S.C. 300gg-
91(d)(8))), any other plan or coverage offered in the small or large
group market, or a grandfathered plan offered in the group market.
Regulations under section 5000A are expected to provide that an
employer-sponsored plan will not fail to be minimum essential coverage
solely because it is a plan to reimburse employees for medical care for
which reimbursement is not provided under a policy of accident and
health insurance (a self-insured plan).
Continuation coverage required under federal law or required under
a state law that provides comparable continuation coverage is eligible
employer-sponsored coverage. The proposed regulations provide a special
rule that an individual eligible to enroll in continuation coverage is
eligible for minimum essential coverage only if the individual enrolls
in the coverage.
The proposed regulations provide that an individual generally is
eligible for minimum essential coverage through an eligible employer-
sponsored plan for a month during a plan year if the individual had the
opportunity to enroll in the plan, even if the enrollment period has
since closed. Thus, once an individual fails to enroll in eligible
employer-sponsored coverage during an employer-sponsored plan's
enrollment period after having had the opportunity to do so (assuming
the coverage is affordable and provides minimum value), the months
during the plan year are not coverage months for the individual,
notwithstanding that the individual is precluded from later enrolling
in the employer-sponsored coverage for those months because the
enrollment period has expired.
Under section 36B(c)(2)(C), an individual generally is eligible for
employer-sponsored minimum essential coverage only if the employee's
share of the premiums is affordable and the coverage provides minimum
value. An individual is treated as eligible for minimum essential
coverage through an eligible employer-sponsored plan, however, if the
individual actually enrolls in the coverage, including coverage that
does not meet the requirements for affordability and minimum value.
B. Affordability of Employer-Sponsored Coverage
Section 36B(c)(2)(C)(i) prescribes the standards for determining
whether employer-sponsored coverage is affordable for an employee as
well as for other individuals. In the case of an employee, under
section 36B(c)(2)(C)(i), an employer-sponsored plan is not affordable
if ``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'' for the taxable year. This
percentage may be adjusted after 2014.\1\
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\1\ In addition, the statute provides for the Comptroller
General, within 5 years of enactment, to conduct a study, including
legislative recommendations, on the affordability of coverage,
including whether the percentage of household income specified in
section 36B(c)(2)(C) ``is the appropriate level for determining
whether employer-provided coverage is affordable for an employee and
whether such level may be lowered without significantly increasing
the costs to the Federal Government and reducing employer-provided
coverage.'' See section 1401(c)(1) of the Affordable Care Act.
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In the case of an individual other than an employee, section
36B(c)(2)(C)(i) provides that ``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.'' The cross-
referenced section 5000A(e)(1)(B) defines the term ``required
contribution'' for this purpose as ``the portion of the annual premium
which would be paid by the individual * * * for self-only coverage.''
Thus, the statutory language specifies that for both employees and
others (such as spouses or dependents) who are eligible to enroll in
employer-sponsored coverage by reason of their relationship to an
employee (related individuals), the coverage is unaffordable if the
required contribution for ``self-only'' coverage (as opposed to family
coverage or other coverage applicable to multiple individuals) exceeds
9.5 percent of household income. See Joint Committee on Taxation,
General Explanation of Tax Legislation Enacted in the 111th Congress,
JCS-2-11 (March 2011) at 265 (stating that, for purposes of the premium
tax credit provisions of the Act, ``[u]naffordable is defined as
coverage with a premium required to be paid by the employee that is
more than 9.5 percent of the employee's household income, based on the
self-only coverage'').
Consistent with these statutory provisions, the proposed
regulations provide that an employer-sponsored plan also is affordable
for a related individual for purposes of section 36B if the employee's
required contribution for self-only coverage under the plan does not
exceed 9.5 percent of the applicable taxpayer's household income for
the taxable year, even if the employee's required contribution for the
family coverage does exceed 9.5 percent of the applicable taxpayer's
household income for the year.
Although the affordability test for related individuals for
purposes of the premium tax credit is based on the cost of self-only
coverage, future proposed regulations under section 5000A are expected
to provide that the affordability test for purposes of applying the
individual responsibility requirement to related individuals is based
on the employee's required contribution for employer-sponsored family
coverage. Section 5000A addresses affordability for employees in
section 5000A(e)(1)(B) and, separately, for related individuals in
section 5000A(e)(1)(C).
C. Employee Affordability Safe Harbor
The proposed regulations provide an employee safe harbor for
individuals who were offered eligible employer-sponsored coverage that
ultimately proves to be affordable based on household income for the
taxable year but who declined the offer because, at the time of
enrollment in a qualified health plan, the Exchange determined that the
employer coverage would be unaffordable. Under the safe harbor, an
eligible employer-sponsored plan is treated as unaffordable for an
entire plan year. Thus, for the months during the plan year (which may
coincide or overlap with the taxable year) a taxpayer will not lose
credit eligibility because, as a result of changes during the taxable
year, the employer coverage would have been affordable based on the
household income for that taxable year. The taxpayer may, however, lose
credit eligibility for other reasons, for example if the taxpayer's
household income for
[[Page 50936]]
the taxable year exceeds 400 percent of the FPL. Regulations under
section 4980H are expected to provide that an employer is not subject
to a penalty merely because an employee receives a premium tax credit
under this employee safe harbor if the employer offered to its
employees affordable coverage that otherwise meets the requirements of
section 4980H.
D. Affordability Safe Harbor for Employers
In general, an applicable large employer (as defined in section
4980H(c)(2)) that offers health coverage to its full-time employees and
their dependents is subject to the assessable payment under section
4980H(b) if at least one full-time employee is certified to receive a
premium tax credit or cost-sharing reduction because the employer-
sponsored coverage either does not provide minimum value or is
unaffordable to the employee.
Employers have commented that they will not know their employees'
actual household income. As a result, even if an employer intends to
offer affordable coverage to all full-time employees, one or more full-
time employees may be certified to receive the premium tax credit, and
the employer may be subject to the assessable payment under 4980H(b).
Future proposed regulations under section 4980H are expected to provide
an affordability safe harbor for employers. Under this anticipated safe
harbor, an employer that meets certain requirements, including offering
its full-time employees (and their dependents) the opportunity to
enroll in eligible employer-sponsored coverage, will not be subject to
an assessable payment under section 4980H(b) with respect to an
employee who receives a premium tax credit or cost-sharing reduction
for a taxable year if the employee portion of the self-only premium for
the employer's lowest cost plan that provides minimum value does not
exceed 9.5 percent of the employee's current W-2 wages from the
employer.
Giving employers the ability to base their affordability
calculations on their employees' wages (which employers know) instead
of employees' household income (which employers generally do not know)
is intended to provide a more workable and predictable method of
facilitating affordable employer-sponsored coverage for the benefit of
both employers and employees. Notwithstanding this safe harbor,
employees' eligibility for a premium tax credit would continue to be
based on affordability of employer-sponsored coverage relative to
employees' household income. Accordingly, some employees--among the
small percentage of employees whose household income is less than their
wages from the employer--would receive a premium tax credit without
resulting in an assessable payment by their employer. The Treasury
Department and the IRS intend to issue a request for comments on this
affordability safe harbor for employers.
E. Minimum Value
Section 36B(c)(2)(C)(ii) provides that an eligible employer-
sponsored plan generally provides minimum value if the plan's share of
the total allowed costs of benefits provided under the plan is at least
60 percent of those costs. Under section 1302(d)(2) of the Affordable
Care Act (42 U.S.C. 18022(d)(2)), regulations to be issued by the
Secretary of Health and Human Services will apply in determining the
percentage of ``the total allowed costs of benefits'' provided under a
group health plan or health insurance coverage that are covered by that
plan or coverage. The regulations under section 1302(d)(2) are expected
to be proposed later this year and to reflect the fact that employer-
sponsored group health plans and health insurance coverage in the large
group market are not required to provide each of the essential health
benefits or each of the 10 categories of benefits described in section
1302(b)(1) of the Affordable Care Act. It is also anticipated that the
regulations will seek to further the objective of preserving the
existing system of employer-sponsored coverage, but without permitting
the statutory employer responsibility standards to be avoided. We also
are contemplating whether to provide appropriate transition relief with
respect to the minimum value requirement for employers currently
offering health care coverage.
2. Computing the Premium Tax Credit
A taxpayer's credit is the sum of the premium assistance amounts
for each coverage month in the taxable year. A premium assistance
amount is computed for each coverage month during the taxable year
based on several factors: household income, family size, applicable
percentage, benchmark plan premium, and actual plan premium. A month
during which no one in the taxpayer's family is enrolled in a qualified
health plan through an Exchange is not a coverage month. A month is a
coverage month only if the taxpayer pays the premium for coverage or
receives the benefit of an advance payment. The premium assistance
amount for a month that is not a coverage month is zero. Household
income is determined on an annual basis and is prorated for each month
to determine the monthly premium assistance amount. The applicable
percentage is the same for each month because it is derived from annual
household income and family size. A taxpayer's benchmark plan premium
may change during the year if, for example, there are changes in the
members of the household covered through the Exchange or the taxpayer
moves to a new State with different plan rates.
a. Premiums Paid on Behalf of the Taxpayer
The proposed regulations provide that, in determining whether a
month is a coverage month, premiums that another person pays for the
coverage of the taxpayer or a family member are treated as paid by the
taxpayer.
b. Applicable Benchmark Plan
Under section 36B(b)(2), the monthly premium for the applicable
second lowest cost silver plan offered through an Exchange is the
benchmark for computing a taxpayer's monthly premium assistance amount.
To determine the amount of premium tax credit, a taxpayer must compute
the difference between the premium for this plan and the applicable
percentage of the taxpayer's household income, regardless of the
qualified health plan the taxpayer purchases.
i. Multiple Categories of Coverage Offered on an Exchange
Section 36B(b)(3)(B)(ii) identifies only self-only and family as
the categories of coverage for the benchmark plan. However, qualified
health plans may offer other categories of coverage based on family
composition, such as children only, two adults, or one adult plus
children. See proposed 45 CFR 156.255(b). Thus, the proposed
regulations define family coverage as any health insurance that covers
more than one individual.
Under the proposed regulations, the ``applicable'' benchmark plan
for a taxpayer is determined by finding the second lowest cost plan at
the silver level that would cover those family members actually
enrolled in a qualified health plan, not eligible for minimum essential
coverage other than coverage in the individual market, not
incarcerated, and lawfully present in the United States (the coverage
family). Thus, the applicable benchmark plan is the self-only category
of coverage for a taxpayer who files as single with no dependents, a
taxpayer who purchases
[[Page 50937]]
self-only coverage, and a taxpayer whose family includes only one
individual who is not eligible for minimum essential coverage or one
lawfully present individual (thus excluding from the credit computation
the portion of the premium attributable to an individual not lawfully
present, as required by section 36B(e)(1)(A)). If an Exchange offers
more categories of coverage than self-only and family, the applicable
benchmark plan is the coverage category that applies to the members of
the taxpayer's coverage family.
ii. Families Who Purchase More Than One Qualified Health Plan
Section 36B determines family size by reference to individuals for
whom the taxpayer claims a personal exemption, and family coverage
under some qualified health plans may not extend to certain tax
dependents (for example, a niece). We note that the Department of
Health and Human Services has requested comments in its proposed
regulations on Exchanges on whether qualified health plans offered on
an Exchange should be required to cover all members of the family if
they live in the same Exchange service area. Pending the issuance of
additional guidance on this issue by Health and Human Services, the
proposed regulations provide that, if the applicable benchmark plan
does not cover a taxpayer's full family, the applicable benchmark plan
premium for these families is the sum of the premiums for the benchmark
plans that cover the taxpayer's family (for example, for an uncle and
two adult dependent nieces, a self-only benchmark plan for the uncle
and a two-adult or family plan for the nieces). The applicable
benchmark plan is similarly modified for taxpayers with family members
residing in different rating areas (also known as Exchange service
areas, see proposed 45 CFR155.20). However, the IRS and Treasury
Department are considering other approaches for determining the
applicable benchmark plan in these cases. For example, the applicable
benchmark plan for these families could be the benchmark plan that
would apply to the family composition (such as one adult plus children)
if one plan covered all members of the taxpayer's family.
Alternatively, the applicable benchmark plan premium could be the
lesser of (1) the premium for a combination of plans that cover the
taxpayer's entire family, or (2) the premium for a single plan that
covers the taxpayer's entire family and is more expensive than the
second lowest cost silver plan. Comments are requested on these and
other possible approaches.
iii. One Qualified Health Plan Covering More Than One Family
If a single qualified health plan covers more than one taxpayer's
family (for example a plan that covers adult children under age 26 who
are not tax dependents), the allowable section 36B credit is computed
for each applicable taxpayer covered by the plan. An individual
applicable percentage is determined for each taxpayer based on the
taxpayer's household income and family size, and the separate
applicable benchmark plan. The premiums for the qualified health plan
the taxpayers purchase are allocated to each taxpayer in proportion to
the premiums for each taxpayer's benchmark plan to determine whether
the premiums paid are less than the benchmark premium minus the
taxpayer's applicable percentage of household income.
iv. Applicable Benchmark Plan That Terminates or Closes to Enrollment
A qualified health plan that is the second lowest cost silver plan
for a particular category of coverage, or the lowest cost silver plan
in that category, may close to enrollment or terminate during the
taxable year. The proposed regulations clarify that an applicable
benchmark plan is a plan offered through the Exchange when a taxpayer
or family member enrolls in a qualified health plan. Unless the
taxpayer or a family member is enrolled in the applicable benchmark
plan, a plan does not cease to be the applicable benchmark plan solely
because the plan or the lowest cost silver plan terminates or closes to
further enrollment during the taxable year.
c. Pediatric Dental Coverage
Section 36B(b)(3)(E) provides that, for purposes of determining the
amount of any monthly premium, if an individual enrolls in both a
qualified health plan and a plan providing dental coverage as described
in section 1311(d)(2)(B)(ii) of the Affordable Care Act (42 U.S.C.
13031(d)(2)(B)(ii)), the portion of the premium for the dental plan
that is properly allocable to pediatric dental benefits that are
essential health benefits is treated as a premium payable for the
individual's qualified health plan. Thus, the portion of the premium
for the separate pediatric dental coverage is added to the premium for
the benchmark plan in computing the credit. Comments are requested on
methods of determining the amount of the premium properly allocable to
pediatric dental benefits.
3. Reconciling the Credit and Advance Credit Payments
The proposed regulations describe the requirements for reconciling
advance payments of the credit with the actual credit amount and
determining the amount of any resulting additional credit or additional
income tax liability. The proposed regulations explain that the credit
is computed by using the household income and family size for the
taxable year, but premium assistance amounts for different coverage
months may be based on different applicable benchmark plans if, for
example, the taxpayer's family composition changes during the taxable
year.
a. Changes in Filing Status
Section 36B(g)(2) directs the Secretary to provide regulations
specifying how to reconcile advance payments with the actual credit
when the taxpayer's filing status on the return claiming the credit
differs from the filing status used to determine advance payments of
the credit. Filing status may be any of the following: single, married
filing jointly, married filing separately, head of household, or
surviving spouse.
i. Computing the Credit When Taxpayer's Marital Status Changes
The proposed regulations provide that, for a taxpayer who has a
change in marital status during the taxable year, the credit generally
is computed according to the same rules that apply to other taxpayers,
using the applicable benchmark plan or plans that apply to the
taxpayer's marital status as of the first day of each month. However,
the proposed regulations include special rules for computing the credit
for taxpayers who divorce during the taxable year. Comments are
requested on special rules for taxpayers who marry during the taxable
year and for married taxpayers who face challenges in being able to
file a joint return.
ii. Taxpayers Who Divorce During the Taxable Year
The proposed regulations provide that, for purposes of
reconciliation, taxpayers who for some months during a taxable year
were married (within the meaning of section 7703) and were covered by
the same qualified health plan but are no longer married on the last
day of the taxable year, may agree to allocate between themselves, in
the same proportion, the premiums for the benchmark plan, premiums paid
and advance credit payments made during the marriage. If the taxpayers
do not agree on an allocation, the taxpayers must allocate 50 percent
of these amounts to each taxpayer. If only one of
[[Page 50938]]
the formerly married taxpayers was enrolled in the plan, 100 percent of
the benchmark premiums, premiums for the plan that taxpayer purchases,
and advance payments are allocated to that taxpayer.
iii. Taxpayers Who Marry During the Taxable Year
For individuals who marry during a taxable year and receive advance
credit payments during the time before they are married, the general
rules for credit computation and reconciliation could lead to the
individuals facing additional tax upon reconciliation, even if the
Exchange accurately determines each individual's separate income for
the year at the time of enrollment. This may occur, for example, in
situations in which the combination of two individuals' household
incomes and families results in the combined family having a higher FPL
percentage than either of the component families would have had if the
individuals had not married, and therefore having a higher applicable
percentage or being ineligible for a credit. Comments are requested on
rules providing relief to certain individuals who would owe additional
tax because they marry during a taxable year when one or both
individuals receive advance credit payments prior to marriage. Comments
are requested on how the premium assistance credit amount should be
computed in this circumstance, including how household income (which is
required to be determined on an annual basis) and dependents for the
taxable year would be taken into account in the credit computation.
iv. Married Taxpayers Filing Separately
Married taxpayers who file their returns as married filing
separately are not applicable taxpayers and generally are ineligible
for the premium tax credit for any month during the taxable year. The
proposed regulations provide that taxpayers who receive advance credit
payments and file their tax returns as married filing separately must
allocate 50 percent of any advance credit payments to each spouse for
purposes of determining their excess advance payment amounts as part of
the reconciliation process. Although the taxpayers owe additional tax
for the entire amount of the advance credit payments, the section
36B(f)(2)(B) repayment limitation applies to each taxpayer whose
household income is below 400 percent of the federal poverty line based
on the household income and family size reported on the return.
Some taxpayers who are married at the time they enroll in a
qualified health plan and begin to receive advance credit payments may
not be able to file a joint return for the coverage year. For example,
in situations involving domestic abuse, when a divorce is pending but
not yet final, or when one spouse is incarcerated, filing a joint
return may not be possible or prudent. Comments are requested on rules
to provide relief for those married taxpayers who have received advance
credit payments but face challenges in being able to file a joint
return. Comments are requested in particular on whether rules should
take into account whether (1) The spouses have filed jointly for the
preceding taxable year, (2) the spouses attested to an expectation to
file jointly for purposes of receiving the advance credit payments, and
(3) the spouses should be allowed relief of this type for more than one
year.
Comments are requested on other rules for reconciling the credit
with advance payments for taxpayers whose filing status changes during
the taxable year.
b. Requirement To File a Return
The proposed regulations require every taxpayer receiving advance
credit payments to file an income tax return on or before the fifteenth
day of the fourth month following the close of the taxable year. The
requirement to file a return applies whether or not a taxpayer is
otherwise required to file a return under section 6012 or claims a
premium tax credit for the taxable year. Under section 6081, the
Commissioner may grant a reasonable extension of time for filing any
income tax return.
Effective/Applicability Date
These regulations are proposed to apply for taxable years ending
after December 31, 2013.
Special Analyses
It has been determined that this notice of proposed rulemaking is
not a significant regulatory action as defined in Executive Order
12866, as supplemented by Executive Order 13563. Therefore, a
regulatory assessment is not required. It has also been determined that
section 553(b) of the Administrative Procedure Act (5 U.S.C. chapter 5)
does not apply to these regulations, and, because the regulations do
not impose a collection of information requirement on small entities,
the Regulatory Flexibility Act (5 U.S.C. chapter 6) does not apply.
Pursuant to section 7805(f) of the Code, this notice of proposed
rulemaking has been submitted to the Chief Counsel for Advocacy of the
Small Business Administration for comment on its impact on small
business.
Comments and Public Hearing
Before these proposed regulations are adopted as final regulations,
consideration will be given to any written comments (either electronic
or a signed paper original and eight (8) copies) that are submitted
timely to the IRS. The IRS and Treasury Department request comments on
the clarity of the proposed rules and how they can be made easier to
understand. All comments will be available for public inspection and
copying.
A public hearing has been scheduled for November 17, 2011, at 10
a.m., in the auditorium, Internal Revenue Building, 1111 Constitution
Avenue, NW., Washington, DC. Due to building security procedures,
visitors must enter at the Constitution Avenue entrance. All visitors
must present photo identification to enter the building. Because of
access restrictions, visitors will not be admitted beyond the immediate
entrance more than 30 minutes before the hearing starts. For
information about having your name placed on the building access list
to attend the hearing, see the FOR FURTHER INFORMATION CONTACT section
of this preamble.
The rules of 26 CFR 601.601(a)(3) apply to the hearing. Persons who
wish to present oral comments at the hearing must submit written
comments (electronic or a signed paper original and eight (8) copies)
and an outline of topics to be discussed and the time devoted to each
topic by November 10, 2011. A period of 10 minutes will be allotted to
each person for making comments.
An agenda showing the scheduling of the speakers will be prepared
after the deadline for receiving outlines has passed. Copies of the
agenda will be available free of charge at the hearing.
Drafting Information
The principal authors of these proposed regulations are Shareen S.
Pflanz, Frank W. Dunham III, and Stephen J. Toomey of the Office of
Associate Chief Counsel (Income Tax and Accounting). However, other
personnel from the IRS and the Treasury Department participated in the
development of the regulations.
List of Subjects in 26 CFR Part 1
Income taxes, Reporting and recordkeeping requirements.
[[Page 50939]]
Proposed Amendments to the Regulations
Accordingly, 26 CFR part 1 is proposed to be amended as follows:
PART 1--INCOME TAXES
Paragraph 1. The authority citation for part 1 is amended by adding
entries in numerical order to read in part as follows:
Authority: 26 U.S.C. 7805 * * *
Section 1.36B-4 also issued under 26 U.S.C. 36B(g).
Par. 2. Sections 1.36B-0, 1.36B-1, 1.36B-2, 1.36B-3, 1.36B-4, and
1.36B-5 are added to read as follows:
Sec. 1.36B-0 Table of contents.
This section lists the captions contained in Sec. Sec. 1.36B-1
through 1.36B-5.
Sec. 1.36B-1 Premium tax credit definitions.
(a) In general.
(b) Affordable Care Act.
(c) Qualified health plan.
(d) Family and family size.
(e) Household income.
(1) In general.
(2) Modified adjusted gross income.
(f) Dependent.
(g) Lawfully present.
(h) Federal poverty line.
(i) Reserved.
(j) Advance credit payment.
(k) Exchange.
(l) Self-only coverage.
(m) Family coverage.
(n) Rating area.
(o) Effective/applicability date.
Sec. 1.36B-2 Eligibility for premium tax credit.
(a) In general.
(b) Applicable taxpayer.
(1) In general.
(2) Married taxpayers must file joint return.
(3) Dependents.
(4) Individuals not lawfully present or incarcerated.
(5) Individuals lawfully present.
(6) Special rule for taxpayers with household income below 100
percent of the federal poverty line for the taxable year.
(7) Computation of premium assistance amounts for taxpayers with
household income below 100 percent of the federal poverty line.
(c) Minimum essential coverage.
(1) In general.
(2) Government-sponsored minimum essential coverage.
(i) In general.
(ii) Special rule for coverage under the veteran's health care
program under chapter 17 or 18 of Title 38, U.S.C.
(iii) Time of eligibility.
(A) In general.
(B) Retroactive effect of eligibility determination.
(iv) Determination of Medicaid or Children's Health Insurance
Program (CHIP) ineligibility.
(v) Examples.
(3) Employer-sponsored minimum essential coverage.
(i) In general.
(ii) Plan year.
(iii) Eligibility for coverage months during a plan year.
(A) In general.
(B) Example.
(iv) Special rule for continuation coverage.
(v) Affordable coverage.
(A) In general.
(1) Affordability.
(2) Employee safe harbor.
(B) Required contribution percentage.
(C) Examples.
(vi) Minimum value.
(vii) Enrollment in eligible employer-sponsored plan.
(A) In general.
(B) Example.
Sec. 1.36B-3 Computing the premium assistance credit amount.
(a) In general.
(b) Definitions.
(c) Coverage month.
(1) In general.
(2) Premiums paid for the taxpayer.
(3) Examples.
(d) Premium assistance amount.
(e) Adjusted monthly premium.
(f) Applicable benchmark plan.
(1) In general.
(2) Family coverage.
(3) Second lowest cost silver plan not covering the taxpayer's
family.
(4) Benchmark plan terminates or closes to enrollment.
(5) Examples.
(g) Applicable percentage.
(1) In general.
(2) Applicable percentage table.
(3) Examples.
(h) Plan covering more than one family.
(1) In general.
(2) Example.
(i) Reserved.
(j) Additional benefits.
(1) In general.
(2) Method of allocation.
(k) Pediatric dental coverage.
(1) In general.
(2) Method of allocation.
(l) Families including individuals not lawfully present.
(1) In general.
(2) Revised household income computation.
(i) Statutory method.
(ii) Comparable method.
Sec. 1.36B-4 Reconciling the premium tax credit with advance credit
payments.
(a) Reconciliation.
(1) In general.
(2) Credit computation.
(3) Limitation on additional tax.
(i) In general.
(ii) Additional tax limitation table.
(4) Examples.
(b) Changes in filing status.
(1) In general.
(2) Taxpayers not married to each other at the end of the taxable
year.
(3) Married taxpayers filing separate returns.
(4) Examples.
Sec. 1.36B-5 Information reporting by Exchanges.
(a) Information required to be reported.
(b) Time and manner of reporting.
Sec. 1.36B-1 Premium tax credit definitions.
(a) In general. Section 36B allows a refundable premium tax credit
for taxable years ending after December 31, 2013. The definitions in
this section apply to this section and Sec. Sec. 1.36B-2 through
1.36B-5.
(b) Affordable Care Act. The term Affordable Care Act refers to the
Patient Protection and Affordable Care Act, Public Law 111-148 (124
Stat. 119 (2010)), and the Health Care and Education Reconciliation Act
of 2010, Public Law 111-152 (124 Stat. 1029 (2010)), as amended by the
Medicare and Medicaid Extenders Act of 2010, Public Law 111-309 (124
Stat. 3285 (2010)), the Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011, Public Law 112-
9 (125 Stat. 36 (2011)), and the Department of Defense and Full-Year
Continuing Appropriations Act, 2011, Public Law 112-10 (125 Stat. 38
(2011)).
(c) Qualified health plan. The term qualified health plan has the
same meaning as in section 1301(a) of the Affordable Care Act (42
U.S.C. 18021(a)) but does not include a catastrophic plan described in
section 1302(e) of the Affordable Care Act (42 U.S.C. 18022(e)).
(d) Family and family size. A taxpayer's family means the
individuals for whom a taxpayer properly claims a deduction for a
personal exemption under section 151 for the taxable year. Family size
means the number of individuals in the family. Family and family size
include an individual who is exempt from the requirement to maintain
minimum essential coverage under section 5000A.
[[Page 50940]]
(e) Household income--(1) In general. Household income means the
sum of--
(i) A taxpayer's modified adjusted gross income; plus
(ii) The aggregate modified adjusted gross income of all other
individuals who--
(A) Are included in the taxpayer's family under paragraph (d) of
this section; and
(B) Are required to file an income tax return for the taxable year
(determined without regard to the exception under section (1)(g)(7) to
the requirement to file a return).
(2) Modified adjusted gross income. Modified adjusted gross income
means adjusted gross income (within the meaning of section 62)
increased by amounts excluded from gross income under section 911 and
tax-exempt interest the taxpayer receives or accrues during the taxable
year.
(f) Dependent. Dependent has the same meaning as in section 152.
(g) Lawfully present. Lawfully present has the same meaning as in
45 CFR 152.2.
(h) Federal poverty line. The federal poverty line means the most
recently published poverty guidelines (updated periodically in the
Federal Register by the Secretary of Health and Human Services under
the authority of 42 U.S.C. 9902(2)) as of the first day of the regular
enrollment period for coverage by a qualified health plan offered
through an Exchange for a calendar year. Thus, the federal poverty line
for computing the premium tax credit for a taxable year is the federal
poverty line in effect on the first day of the initial or annual open
enrollment period preceding that taxable year. See 45 CFR 155.410.
(i) [Reserved]
(j) Advance credit payment. Advance credit payment means an advance
payment of the premium tax credit as provided in section 1412 of the
Affordable Care Act (42 U.S.C. 18082).
(k) Exchange. Exchange has the same meaning as in 45 CFR 155.20.
(l) Self-only coverage. Self-only coverage means health insurance
that covers one individual.
(m) Family coverage. Family coverage means health insurance that
covers more than one individual.
(n) Rating area. Rating area means an Exchange service area, as
described in 45 CFR 155.20.
(o) Effective/applicability date. This section and Sec. Sec.
1.36B-2 through 1.36B-5 apply for taxable years ending after December
31, 2013.
Sec. 1.36B-2 Eligibility for premium tax credit.
(a) In general. An applicable taxpayer (within the meaning of
paragraph (b) of this section) is allowed a premium assistance amount
only for any month that the applicable taxpayer, or the applicable
taxpayer's spouse or dependent--
(1) Is enrolled in one or more qualified health plans through an
Exchange; and
(2) Is not eligible for minimum essential coverage (within the
meaning of paragraph (c) of this section) other than coverage described
in section 5000A(f)(1)(C) (relating to coverage in the individual
market).
(b) Applicable taxpayer--(1) In general. Except as otherwise
provided in this paragraph (b), an applicable taxpayer is a taxpayer
whose household income is at least 100 percent but not more than 400
percent of the federal poverty line for the taxpayer's family size for
the taxable year.
(2) Married taxpayers must file joint return. A taxpayer who is
married (within the meaning of section 7703) at the close of the
taxable year is an applicable taxpayer only if the taxpayer and the
taxpayer's spouse file a joint return for the taxable year.
(3) Dependents. An individual is not an applicable taxpayer if
another taxpayer may claim a deduction under section 151 for the
individual for a taxable year beginning in the calendar year in which
the individual's taxable year begins.
(4) Individuals not lawfully present or incarcerated. An individual
who is not lawfully present in the United States or is incarcerated
(other than incarceration pending disposition of charges) may not be
covered by a qualified health plan through an Exchange. However, the
individual may be an applicable taxpayer if a family member is eligible
to enroll in a qualified health plan. See sections 1312(f)(1)(B) and
1312(f)(3) of the Affordable Care Act (42 U.S.C. 18032(f)(1)(B) and
(f)(3)) and Sec. 1.36B-3(b)(2).
(5) Individuals lawfully present. If a taxpayer's household income
is less than 100 percent of the federal poverty line for the taxpayer's
family size and the taxpayer or a member of the taxpayer's family is an
alien lawfully present in the United States, the taxpayer is treated as
an applicable taxpayer if--
(i) The taxpayer or family member is not eligible for the Medicaid
program; and
(ii) The taxpayer would be an applicable taxpayer if the taxpayer's
household income for the taxable year was between 100 and 400 percent
of the federal poverty line for the taxpayer's family size.
(6) Special rule for taxpayers with household income below 100
percent of the federal poverty line for the taxable year. A taxpayer
(other than a taxpayer described in paragraph (b)(5) of this section)
whose household income for a taxable year is less than 100 percent of
the federal poverty line for the taxpayer's family size is treated as
an applicable taxpayer if--
(i) The taxpayer or a family member enrolls in a qualified health
plan through an Exchange;
(ii) An Exchange estimates at the time of enrollment that the
taxpayer's household income will be between 100 and 400 percent of the
federal poverty line for the taxable year;
(iii) Advance credit payments are authorized and paid for one or
more months during the taxable year; and
(iv) The taxpayer would be an applicable taxpayer if the taxpayer's
household income for the taxable year was between 100 and 400 percent
of the federal poverty line for the taxpayer's family size.
(7) Computation of premium assistance amounts for taxpayers with
household income below 100 percent of the federal poverty line. If a
taxpayer is treated as an applicable taxpayer under paragraph (b)(5) or
(b)(6) of this section, the taxpayer's actual household income for the
taxable year is used to compute the premium assistance amounts under
Sec. 1.36B-3(d).
(c) Minimum essential coverage--(1) In general. Minimum essential
coverage is defined in section 5000A(f) and regulations issued under
that section. As described in section 5000A(f), government-sponsored
programs, eligible employer-sponsored plans, grandfathered health
plans, and certain other health benefits coverage are minimum essential
coverage.
(2) Government-sponsored minimum essential coverage--(i) In
general. Except as provided in paragraph (c)(2)(ii) of this section,
for purposes of section 36B, an individual is eligible for government-
sponsored minimum essential coverage if the individual meets the
criteria for coverage under a government-sponsored program described in
section 5000A(f)(1)(A). The Commissioner may define eligibility for
specific government-sponsored programs further in published guidance of
general applicability, see Sec. 601.601(d)(2) of this chapter.
(ii) Special rule for coverage under the veteran's health care
program under chapter 17 or 18 of Title 38, U.S.C. An individual is
eligible for minimum
[[Page 50941]]
essential coverage under the veteran's health care program authorized
under chapter 17 or 18 of Title 38, U.S.C., only if the individual is
enrolled in a veteran's health care program identified as minimum
essential coverage in regulations issued under section 5000A.
(iii) Time of eligibility--(A) In general. An individual generally
is treated as eligible for a government-sponsored program on the first
day of the first full month in which the individual may receive
benefits under the program. However, an individual who fails to
complete the requirements necessary to receive benefits available under
a government-sponsored program (other than a veteran's health care
program) reasonably promptly is treated as eligible for government-
sponsored minimum essential coverage as of the first day of the second
calendar month following the event that establishes eligibility under
paragraph (c)(2)(i) of this section.
(B) Retroactive effect of eligibility determination. If an
individual receiving advance credit payments is determined to be
eligible for government-sponsored minimum essential coverage that is
effective retroactively (such as Medicaid), the individual is treated
as eligible for minimum essential coverage under that program no
earlier than the first day of the first calendar month beginning after
the approval.
(iv) Determination of Medicaid or Children's Health Insurance
Program (CHIP) ineligibility. An individual is treated as not eligible
for Medicaid, CHIP, or a similar program for a period of coverage under
a qualified health plan if an Exchange determines that the individual
is not eligible for the program when the individual enrolls in the
qualified health plan.
(v) Examples. The following examples illustrate the provisions of
this paragraph (c)(2).
Example 1. Delay in coverage effectiveness. On April 10,
Taxpayer D applies for coverage under a government-sponsored health
care program. D's application is approved on July 12 but her
coverage is not effective until September 1. Under paragraph
(c)(2)(iii)(A) of this section, D is eligible for government-
sponsored minimum essential coverage on September 1.
Example 2. Time of eligibility. Taxpayer E turns 65 on June 3
and becomes eligible for Medicare. Under section 5000A(f)(1)(A),
Medicare is minimum essential coverage. However, E must enroll in
Medicare to receive benefits. E enrolls in Medicare on June 11 and
may receive benefits immediately. Under paragraph (c)(2)(iii)(A) of
this section, E is eligible for government-sponsored minimum
essential coverage on July 1, the first day of the first full month
that E may receive benefits under the program.
Example 3. Time of eligibility, individual fails to complete
necessary requirements. The facts are the same as in Example 2,
except that E fails to enroll in the Medicare coverage. E is treated
as eligible for government-sponsored minimum essential coverage
under paragraph (c)(2)(iii)(A) of this section as of August 1, the
first day of the second month following the event that establishes
eligibility (E turning 65).
Example 4. Retroactive effect of eligibility. On April 10, 2015,
Taxpayer G applies for coverage under the Medicaid program. G's
application is approved on May 15, 2015, and her Medicaid coverage
is effective as of April 1, 2015. Under paragraph (c)(2)(iii)(B) of
this section, G is eligible for government-sponsored minimum
essential coverage on June 1, 2015, the first day of the first
calendar month after approval.
Example 5. Determination of Medicaid ineligibility. In November
2014, Taxpayer H applies to the Exchange to enroll in a qualified
health plan and for advance credit payments for 2015. The Exchange
estimates that H's household income will be 140 percent of the
federal poverty line for H's family size and determines that H is
not eligible for Medicaid. The Exchange authorizes advance credit
payments for H for 2015. H experiences a loss of household income in
June 2015 but does not return to the Exchange in 2015 to apply for
Medicaid benefits or report his change in income. H's household
income for 2015 is 130 percent of the federal poverty line (within
the Medicaid income threshold). Under paragraph (c)(2)(iv) of this
section, H is treated as not eligible for Medicaid for 2015.
Example 6. Mid-year Medicaid eligibility redetermination. The
facts are the same as in Example 5, except that H returns to the
Exchange in July 2015 and the Exchange determines H is eligible for
Medicaid. The Exchange discontinues H's advance credit payments
effective August 1. Under paragraphs (c)(2)(iii)(B) and (c)(2)(iv)
of this section, H is treated as not eligible for Medicaid for the
coverage months when H is covered by a qualified health plan. H is
eligible for government-sponsored minimum essential coverage for the
coverage months after H is approved for Medicaid, August through
December 2015.
(3) Employer-sponsored minimum essential coverage--(i) In general.
For purposes of section 36B, an employee who may enroll in an eligible
employer-sponsored plan (as defined in section 5000A(f)(2)) and an
individual who may enroll in the plan because of a relationship to the
employee (a related individual) are eligible for minimum essential
coverage under the plan for any month only if the plan is affordable
and provides minimum value. Government-sponsored programs described in
section 5000A(f)(1)(A) are not eligible employer-sponsored plans.
(ii) Plan year. For purposes of this paragraph (c)(3), a plan year
is an eligible employer-sponsored plan's regular 12-month coverage
period (or the remainder of a 12-month coverage period for a new
employee or an individual who enrolls during a special enrollment
period).
(iii) Eligibility for coverage months during a plan year--(A) In
general. An employee or related individual may be eligible for minimum
essential coverage under an eligible employer-sponsored plan for a
coverage month during a plan year if the employee or related individual
could have enrolled in the plan for that month during an open or
special enrollment period.
(B) Example. The following example illustrates the provisions of
this paragraph (c)(3)(iii).
Example. (i) Taxpayer B is an employee of Employer X. X offers
its employees a health insurance plan that has a plan year (within
the meaning of paragraph (c)(3)(ii) of this section) from October 1
through September 30. Employees may enroll during an open season
from August 1 to September 15. B does not enroll in X's plan for the
plan year October 1, 2014, to September 30, 2015. In November 2014 B
enrolls in a qualified health plan through an Exchange for calendar
year 2015.
(ii) B could have enrolled in X's plan during the August 1 to
September 15 enrollment period. Therefore, unless X's plan is not
affordable for B or does not provide minimum value, B is eligible
for minimum essential coverage for the months that B is enrolled in
the qualified health plan during X's plan year (January through
September 2015).
(iv) Special rule for continuation coverage. An individual who may
enroll in continuation coverage required under federal law or a state
law that provides comparable continuation coverage is eligible for
minimum essential coverage only if the individual enrolls in the
coverage.
(v) Affordable coverage--(A) In general--(1) Affordability. Except
as provided in paragraph (c)(3)(v)(A)(2) of this section, an eligible
employer-sponsored plan is affordable for an employee or a related
individual if the portion of the annual premium the employee must pay,
whether by salary reduction or otherwise (required contribution), for
self-only coverage for the taxable year does not exceed the required
contribution percentage (as defined in paragraph (c)(3)(v)(B) of this
section) of the applicable taxpayer's household income for the taxable
year.
(2) Employee safe harbor. An employer-sponsored plan is treated as
not affordable for an employee or a related individual for a plan year
if, when the employee or a related individual enrolls in a qualified
health plan for a period coinciding with the plan year (in whole or in
part), an Exchange determines that the eligible
[[Page 50942]]
employer-sponsored plan is not affordable.
(B) Required contribution percentage. The required contribution
percentage is 9.5 percent. The percentage may be adjusted in published
guidance of general applicability, see Sec. 601.601(d)(2) of this
chapter, for taxable years beginning after December 31, 2014, to
reflect rates of premium growth relative to growth in income and, for
taxable years beginning after December 31, 2018, to reflect rates of
premium growth relative to growth in the consumer price index.
(C) Examples. The following examples illustrate the provisions of
this paragraph (c)(3)(v). Unless stated otherwise, in each example the
taxpayer is single and has no dependents, the employer's plan is an
eligible employer-sponsored plan and provides minimum value, the
employee is not eligible for other minimum essential coverage, and the
taxpayer, related individual, and employer-sponsored plan have a
calendar taxable year.
Example 1. Basic determination of affordability. In 2014
Taxpayer C has household income of $47,000. C is an employee of
Employer X, which offers its employees a health insurance plan that
requires C to contribute $3,450 for self-only coverage for 2014 (7.3
percent of C's household income). Because C's required contribution
for self-only coverage does not exceed 9.5 percent of household
income, under paragraph (c)(3)(v)(A)(1) of this section, X's plan is
affordable for C, and C is eligible for minimum essential coverage
for all months in 2014.
Example 2. Basic determination of affordability for a related
individual. The facts are the same as in Example 1, except that C is
married to J and X's plan requires C to contribute $5,300 for
coverage for C and J for 2014 (11.3 percent of C's household
income). Because C's required contribution for self-only coverage
($3,450) does not exceed 9.5 percent of household income, under
paragraph (c)(3)(v)(A)(1) of this section, X's plan is affordable
for C and J, and C and J are eligible for minimum essential coverage
for all months in 2014.
Example 3. Determination of unaffordability at enrollment. (i)
Taxpayer D is an employee of Employer X. In November 2013 the
Exchange in D's rating area projects that D's 2014 household income
will be $37,000. It also verifies that D's required contribution for
self-only coverage under X's health insurance plan will be $3,700
(10 percent of household income). Consequently, the Exchange
determines that X's plan is unaffordable. D enrolls in a qualified
health plan and not in X's plan. In December 2014, X pays D a $2,500
bonus. Thus, D's actual 2014 household income is $39,500 and D's
required contribution for coverage under X's plan is 9.4 percent of
household income.
(ii) Based on D's actual 2014 household income, D's required
contribution does not exceed 9.5 percent of household income and X's
health plan is affordable for D. However, when D enrolled in a
qualified health plan for 2014, the Exchange determined that X's
plan was not affordable for D for 2014. Consequently, under
paragraph (c)(3)(v)(A)(2) of this section, X's plan is treated as
not affordable for D and D is treated as not eligible for minimum
essential coverage for 2014.
Example 4. Determination of unaffordability for plan year. The
facts are the same as in Example 3, except that X's employee health
insurance plan year is September 1 to August 31. The Exchange in D's
rating area determines in August 2014 that X's plan is unaffordable
for D based on D's projected household income for 2014. D enrolls in
a qualified health plan as of September 1, 2014. Under paragraph
(c)(3)(v)(A)(2) of this section, X's plan is treated as not
affordable for D and D is treated as not eligible for minimum
essential coverage under X's plan for the coverage months September
to December 2014 and January through August 2015.
Example 5. Determination of unaffordability for part of plan
year. (i) Taxpayer E is an employee of Employer X beginning in May
2015. X's employee health insurance plan year is September 1 to
August 31. E's required contribution for self-only coverage for May
through August is $150 per month ($1,800 for the full plan year).
The Exchange in E's rating area determines E's household income for
purposes of eligibility for advance credit payments as $18,000. E's
actual household income for the 2015 taxable year is $20,000.
(ii) Whether coverage under X's plan is affordable for E is
determined for the remainder of X's plan year (May through August).
E's required contribution for a full plan year ($1,800) exceeds 9.5
percent of E's household income (1,800/18,000 = 10 percent).
Therefore, the Exchange determines that X's coverage is unaffordable
for May through August. Although E's actual household income for
2015 is $20,000 (and E's required contribution of $1,800 does not
exceed 9.5 percent of E's household income), under paragraph
(c)(3)(v)(A)(2) of this section, X's plan is treated as unaffordable
for E for the part of the plan year May through August 2015.
Consequently, E is not eligible for minimum essential coverage under
X's plan for the period May through August 2015.
Example 6. Affordability determined for part of a taxable year
(part-year period). (i) Taxpayer F is an employee of Employer X. X's
employee health insurance plan year is September 1 to August 31. F's
required contribution for self-only coverage for the period
September 2014 through August 2015 is $150 per month or $1,800 for
the plan year. F does not ask the Exchange in his rating area to
determine whether X's coverage is affordable for F. F does not
enroll in X's plan during X's open season but enrolls in a qualified
health plan for September through December 2014. F's household
income in 2014 is $18,000.
(ii) Because F is a calendar year taxpayer and Employer X's plan
is not a calendar year plan, F must determine the affordability of
X's coverage for the part-year period in 2014 (September-December).
F determines the affordability of X's plan for the September through
December 2014 period by comparing the annual premiums ($1,800) to
F's 2014 household income. F's required contribution of $1,800 is 10
percent of F's 2014 household income. Because F's required
contribution exceeds 9.5 percent of F's 2014 household income, X's
plan is not affordable for F for the part-year period September
through December 2014 and F is not eligible for minimum essential
coverage under X's plan for that period.
(iii) F enrolls in Exchange coverage for 2015 and does not ask
the Exchange to determine whether X's coverage is affordable. F's
2015 household income is $20,000.
(iv) F must determine if X's plan is affordable for the part-
year period January 2015 through August 2015. F's annual required
contribution ($1,800) is 9 percent of F's 2015 household income.
Because F's required contribution does not exceed 9.5 percent of F's
2015 household income, X's plan is affordable for F for the part-
year period January through August 2015 and F is eligible for
minimum essential coverage for that period.
Example 7. Coverage unaffordable at year end. Taxpayer G is
employed by Employer X. In November 2014 the Exchange in G's rating
area determines that G is eligible for affordable employer-sponsored
coverage for 2015. G nonetheless enrolls in a qualified health plan
for 2015 but does not receive advance credit payments. G's 2015
household income is less than expected and G's required contribution
for employer-sponsored coverage for 2015 exceeds 9.5 percent of G's
actual 2015 household income. Under paragraph (c)(3)(v)(A)(1) of
this section, G is not eligible for minimum essential coverage for
2015 and, if otherwise eligible, G may claim a premium tax credit.
(vi) Minimum value. An eligible employer-sponsored plan provides
minimum value only if the plan's share of the total allowed costs of
benefits provided under the plan (as determined under regulations
issued by the Secretary of Health and Human Services under section
1302(d)(2) of the Affordable Care Act (42 U.S.C. 18022(d)(2))) is at
least 60 percent.
(vii) Enrollment in eligible employer-sponsored plan--(A) In
general. The requirements of affordability and minimum value do not
apply if an individual enrolls in an eligible employer-sponsored plan.
(B) Example. The following example illustrates the provisions of
this paragraph (c)(3)(vii).
Example. Taxpayer H is employed by Employer X in 2014. H's
required contribution for employer coverage exceeds 9.5 percent of
H's 2014 household income. H enrolls in X's plan for 2014. Under
paragraph (c)(3)(vii) of this section, H is eligible for minimum
essential coverage for 2014 because H is enrolled in an eligible
employer-sponsored plan for 2014.
[[Page 50943]]
Sec. 1.36B-3 Computing the premium assistance credit amount.
(a) In general. A taxpayer's premium assistance credit amount for a
taxable year is the sum of the premium assistance amounts determined
under paragraph (d) of this section for all coverage months for
individuals in the taxpayer's family.
(b) Definitions. For purposes of this section--
(1) The cost of a qualified health plan is the premium the plan
charges; and
(2) The term coverage family refers to members of the taxpayer's
family who are not eligible for minimum essential coverage (other than
coverage in the individual market), are lawfully present in the United
States, and are not incarcerated (except pending disposition of
charges).
(c) Coverage month--(1) In general. A month is a coverage month for
an individual if, as of the first day of the month--
(i) The individual is covered by a qualified health plan enrolled
in through an Exchange;
(ii) The individual's premiums for coverage under the plan are paid
by the taxpayer or by an advance credit payment; and
(iii) The individual is not eligible for minimum essential coverage
(within the meaning of Sec. 1.36B-2(c)) other than coverage described
in section 5000A(f)(1)(C) (relating to coverage in the individual
market).
(2) Premiums paid for the taxpayer. Premiums another person pays
for coverage of the taxpayer, taxpayer's spouse, or dependent are
treated as paid by the taxpayer.
(3) Examples. The following examples illustrate the provisions of
this paragraph (c). In each example, unless stated otherwise, the
individuals are not eligible for minimum essential coverage other than
coverage in the individual market and the taxpayer is an applicable
taxpayer.
Example 1. (i) Taxpayer M is single with no dependents. In
December 2013 M enrolls in a qualified health plan for 2014 and the
Exchange approves advance credit payments. On May 15, 2014, M
enlists in the U.S. Army and is eligible immediately for government-
sponsored minimum essential coverage.
(ii) Under paragraph (c)(1) of this section, January through May
2014 are coverage months for M. June through December 2014 are not
coverage months because M is eligible for minimum essential coverage
for those months. Thus, under paragraph (a) of this section, M's
premium assistance credit amount for 2014 is the sum of the premium
assistance amounts for the months January through May.
Example 2. (i) Taxpayer N has one dependent, S. S is eligible
for government-sponsored minimum essential coverage. N is not
eligible for minimum essential coverage. N enrolls in a qualified
health plan for 2014 and the Exchange approves advance credit
payments. On August 1, 2014, S loses eligibility for minimum
essential coverage. N cancels the qualified health plan that covers
only N and enrolls in a qualified health plan that covers N and S
for August through December 2014.
(ii) Under paragraph (c)(1) of this section, January through
December of 2014 are coverage months for N and August through
December are coverage months for N and S. N's premium assistance
credit amount for 2014 is the sum of the premium assistance amounts
for these coverage months.
Example 3. (i) O and P are the divorced parents of T. Under the
divorce agreement between O and P, T resides with P and P claims T
as a dependent. However, O must pay premiums for health insurance
for T. P enrolls T in a qualified health plan for 2014. O pays the
premiums to the insurance company.
(ii) Because P claims T as a dependent, P (and not O) may claim
a premium tax credit for coverage for T. See Sec. 1.36B-2(a). Under
paragraph (c)(2) of this section, the premiums that O pays for
coverage for T are treated as paid by P. Thus, the months when T is
covered by a qualified health plan are coverage months under
paragraph (c)(1) of this section in computing P's premium tax credit
under paragraph (a) of this section.
(d) Premium assistance amount. The premium assistance amount for a
coverage month is the lesser of--
(1) The premiums for the month for one or more qualified health
plans in which a taxpayer or a member of the taxpayer's family enrolls;
or
(2) The excess of the adjusted monthly premium for the applicable
benchmark plan over \1/12\ of the product of a taxpayer's household
income and the applicable percentage for the taxable year.
(e) Adjusted monthly premium. The adjusted monthly premium is the
premium an insurer would charge for the applicable benchmark plan to
cover all members of the taxpayer's coverage family, adjusted only for
the age of each member of the coverage family as allowed under section
2701 of the Public Health Service Act (42 U.S.C. 300gg).
(f) Applicable benchmark plan--(1) In general. Except as otherwise
provided in this paragraph (f), the applicable benchmark plan for a
coverage month is the second lowest cost silver plan (as described in
section 1302(d)(1)(B) of the Affordable Care Act (42 U.S.C.
18022(d)(1)(B))) offered at the time a taxpayer or family member
enrolls in a qualified health plan through the Exchange in the rating
area where the taxpayer resides for--
(i) Self-only coverage for a taxpayer--
(A) Who computes tax under section 1(c) (unmarried individuals
other than surviving spouses and heads of household) and is not allowed
a deduction under section 151 for a dependent for the taxable year;
(B) Who purchases only self-only coverage for one individual; or
(C) Whose coverage family includes only one individual; and
(ii) Family coverage for all other taxpayers.
(2) Family coverage. If an Exchange offers categories of family
coverage (for example, two adults, one adult with children, two or more
adults with children, or children only), the applicable benchmark plan
for family coverage is the coverage category that applies to the
members of the taxpayer's coverage family who enroll in a qualified
health plan (such as a plan covering two adults if the members of
taxpayer's coverage family are two adults).
(3) Second lowest cost silver plan not covering the taxpayer's
family. If the applicable benchmark plan determined under paragraphs
(f)(1) and (f)(2) of this section does not cover all members of a
taxpayer's coverage family (for example, because family members reside
in different rating areas), the premium for the applicable benchmark
plan is the sum of the premiums for the applicable benchmark plans
determined under paragraphs (f)(1) and (f)(2) of this section that
cover the components of the taxpayer's coverage family.
(4) Benchmark plan terminates or closes to enrollment. A qualified
health plan that is the applicable benchmark plan under this paragraph
(f) for a taxpayer does not cease to be the applicable benchmark plan
solely because the plan or a lower cost plan terminates or closes to
enrollment during the taxable year.
(5) Examples. The following examples illustrate the rules of this
paragraph (f). In each example, unless otherwise stated, the taxpayer
is eligible to receive a premium tax credit.
Example 1. Single taxpayer with no dependents. Taxpayer V is
single and resides with his 24-year-old daughter but may not claim
her as a dependent. Taxpayer V purchases family coverage for himself
and his daughter. The exchange in V's rating area offers only self-
only and family coverage categories. Under paragraph (f)(1)(i)(A) of
this section, V's applicable benchmark plan is the second lowest
cost silver self-only plan. But see paragraph (h) of this section
for computing the credit when multiple taxpayers are covered by one
qualified health plan.
Example 2. Single taxpayer with one dependent, two coverage
categories. The facts are the same as in Example 1, except that V
[[Page 50944]]
also resides with his teenage son and claims him as a dependent. V
purchases family coverage for himself, his son, and his daughter.
Under paragraph (f)(1)(ii) of this section, V's applicable benchmark
plan is the second lowest cost silver family plan.
Example 3. Single taxpayer with one dependent, multiple coverage
categories. The facts are the same as in Example 2, except that the
Exchange where V resides offers a category of coverage for one adult
and children. Under paragraphs (f)(1)(ii) and (f)(2) of this
section, V's applicable benchmark plan is the second lowest cost
silver plan for one adult plus children.
Example 4. Single taxpayer with one dependent, multiple coverage
categories. The facts are the same as in Example 2, except that the
Exchange where V resides offers a category of coverage for one adult
and one child in addition to coverage for one adult and children.
Under paragraphs (f)(1)(ii) and (f)(2) of this section, V's
applicable benchmark plan is the second lowest cost silver plan for
one adult and one child.
Example 5. Applicable benchmark plan unrelated to coverage
purchased. Taxpayers W and X, who are married, reside with X's two
teenage daughters, whom they claim as dependents. The Exchange where
W and X reside offers a category of coverage for one adult plus
children. W and X purchase self-only coverage for W and one adult
plus children coverage for X and X's daughters. Under paragraph
(f)(1)(ii) of this section, W's and X's applicable benchmark plan is
the second lowest cost silver family plan.
Example 6. Minimum essential coverage for some coverage months.
Taxpayer Y claims his daughter as a dependent. Y and his daughter
enroll in a qualified health plan for 2014. The exchange in Y's
rating area offers only self-only and family coverage categories. Y,
but not his daughter, is eligible for government-sponsored minimum
essential coverage for September to December 2014. Thus, under
paragraph (c)(1)(iii) of this section, January through December are
coverage months for Y's daughter and January through August are
coverage months for Y. Because, under paragraphs (d) and (f)(1) of
this section, the premium assistance amount for a coverage month is
computed based on the applicable benchmark plan for that coverage
month, Y's applicable benchmark plan for January through August is
the second lowest cost silver family plan under paragraph (f)(1)(ii)
of this section. Under paragraph (f)(1)(i)(C) of this section, Y's
applicable benchmark plan for September through December is the
second lowest cost silver self-only plan.
Example 7. Family member eligible for minimum essential coverage
for the taxable year. The facts are the same as in Example 6, except
that Y is not eligible for government-sponsored minimum essential
coverage for any months and Y's daughter is eligible for government-
sponsored minimum essential coverage for the entire year. Under
paragraph (f)(1)(i)(C) of this section, Y's applicable benchmark
plan is the second lowest cost silver self-only plan.
Example 8. Family required to buy multiple plans to obtain
coverage. (i) Taxpayers X and Z are married and live in different
Exchange rating areas. X and Z have one child, M, whom they claim as
a dependent and who resides with X. X and M enroll in a qualified
health plan covering one adult plus children through the Exchange in
X's rating area, and Z enrolls in a qualified health plan providing
self-only coverage through the Exchange in Z's rating area.
(ii) Under paragraph (f)(3) of this section, the premium for the
applicable benchmark plan for computing X's and Z's premium
assistance credit amount is the sum of the premium for the second
lowest cost silver one adult plus children plan offered through the
Exchange in X's rating area and the premium for the second lowest
cost silver self-only plan offered through the Exchange in Z's
rating area.
Example 9. Benchmark plan closes to new enrollees during the
year. Taxpayers X, Y, and Z each have coverage families consisting
of two adults. In the rating area where X, Y, and Z reside, Plan 2
is the second lowest cost silver plan and Plan 3 is the third lowest
cost silver plan covering two adults offered through the Exchange.
The X and Y families each enroll in a qualified health plan that is
not the applicable benchmark plan in November during the regular
open enrollment period. Plan 2 closes to new enrollees the following
June. Thus, on July 1, Plan 3 is the second lowest cost silver plan
available to new enrollees through the Exchange. The Z family
enrolls in a qualified health plan in July. Under paragraphs (f)(1),
(f)(2), and (f)(4) of this section, the applicable benchmark plan is
Plan 2 for X and Y for all coverage months during the year. The
applicable benchmark plan for Z is Plan 3, because Plan 2 is not
offered through the Exchange when the Z family enrolls.
Example 10. Benchmark plan terminates for all enrollees during
the year. The facts are the same as in Example 9, except that Plan 2
terminates for all enrollees on June 30. Under paragraphs (f)(1),
(f)(2), and (f)(4) of this section, Plan 2 is the applicable
benchmark plan for X and Y for all coverage months during the year
and Plan 3 is the applicable benchmark plan for Z.
(g) Applicable percentage--(1) In general. The applicable
percentage multiplied by a taxpayer's household income determines the
taxpayer's required share of premiums for the benchmark plan. This
amount is subtracted from the adjusted monthly premium for the
applicable benchmark plan when computing the premium assistance amount.
The applicable percentage is computed by first determining the
percentage that the taxpayer's household income bears to the federal
poverty line for the taxpayer's family size. The resulting federal
poverty line percentage is then compared to the income categories
described in the table in paragraph (g)(2) of this section (or
successor tables). An applicable percentage within an income category
increases on a sliding scale in a linear manner and is rounded to the
nearest one-hundredth of one percent. The applicable percentages in the
table may be adjusted in published guidance of general applicability,
see Sec. 601.601(d)(2) of this chapter, for taxable years beginning
after December 31, 2014, to reflect rates of premium growth relative to
growth in income and, for taxable years beginning after December 31,
2018, to reflect rates of premium growth relative to growth in the
consumer price index.
(2) Applicable percentage table.
------------------------------------------------------------------------
Household income percentage of
federal poverty line Initial percentage Final percentage
------------------------------------------------------------------------
Less than 133%.................. 2.0 2.0
At least 133% but less than 150% 3.0 4.0
At least 150% but less than 200% 4.0 6.3
At least 200% but less than 250% 6.3 8.05
At least 250% but less than 300% 8.05 9.5
At least 300% but less than 400% 9.5 9.5
------------------------------------------------------------------------
(3) Examples. The following examples illustrate the rules of this
paragraph (g).
Example 1. A's household income is 275 percent of the federal
poverty line for A's family size for that taxable year. In the table
in paragraph (g)(2) of this section, the initial percentage for a
taxpayer with household income of 250 to 300 percent of the federal
poverty line is 8.05 and the final percentage is 9.5. A's federal
poverty line percentage of 275 percent is halfway between 250
percent and 300 percent. Thus, rounded to the nearest one-hundredth
of one percent, A's applicable percentage is 8.78, which is halfway
between the initial percentage of 8.05 and the final percentage of
9.5.
Example 2. (i) B's household income is 210 percent of the
federal poverty line for B's family size. In the table in paragraph
(g)(2) of this section, the initial percentage for a taxpayer with
household income of 200 to 250 percent of the federal poverty line
is 6.3 and the final percentage is 8.05. B's applicable percentage
is 6.65, computed as follows:
[[Page 50945]]
(ii) Determine the excess of B's FPL percentage (210) over the
initial household income percentage in B's range (200), which is 10.
Determine the difference between the initial household income
percentage in the taxpayer's range (200) and the ending household
income percentage in the taxpayer's range (250), which is 50. Divide
the first amount by the second amount:
210 - 200 = 10
250 - 200 = 50
10/50 = .20.
(iii) Compute the difference between the initial premium percentage
(6.3) and the second premium percentage (8.05) in the taxpayer's range;
8.05 - 6.3 = 1.75.
(iv) Multiply the amount in the first calculation (.20) by the
amount in the second calculation (1.75) and add the product (.35) to
the initial premium percentage in B's range (6.3), resulting in B's
applicable percentage of 6.65:
.20 x 1.75 = .35
6.3 + .35 = 6.65.
(h) Plan covering more than one family--(1) In general. If a single
qualified health plan covers more than one family, each applicable
taxpayer covered by the plan may claim a premium tax credit, if
otherwise allowable. Each taxpayer computes the credit using that
taxpayer's applicable percentage, household income, and the benchmark
plan that applies to the taxpayer under paragraph (f) of this section.
In determining whether the amount computed under paragraph (d)(1) of
this section (the premiums for the qualified health plan in which the
taxpayer enrolls) is less than the amount computed under paragraph
(d)(2) of this section (the benchmark plan premium minus the product of
household income and the applicable percentage), the premiums paid are
allocated to each taxpayer in proportion to the premiums for each
taxpayer's benchmark plan.
(2) Example. The following example illustrates the rules of this
paragraph (h).
Example. (i) Taxpayers A and B enroll in a single qualified
health plan. B is A's 25-year-old child who is not A's dependent. B
has no dependents. The plan covers A, B, and A's two children who
are A's dependents. The premium for the plan in which A and B enroll
is $15,000. The premium for the second lowest cost silver family
plan is $12,000 and the premium for the second lowest cost silver
self-only plan is $6,000. A and B are applicable taxpayers and
otherwise eligible to claim the premium tax credit.
(ii) Under paragraph (h)(1) of this section, both A and B may
claim premium tax credits. A computes her credit using her household
income, a family size of three, and a benchmark plan premium of
$12,000. B computes his credit using his household income, a family
size of one, and a benchmark plan premium of $6,000.
(iii) In determining whether the amount in paragraph (d)(1) of
this section (the premiums for the qualified health plan A and B
purchase) is less than the amount in paragraph (d)(2) of this
section (the benchmark plan premium minus the product of household
income and the applicable percentage), the $15,000 premiums paid are
allocated to A and B in proportion to the premiums for their
applicable benchmark plans. Thus, the portion of the premium
allocated to A is $10,000 ($15,000 x $12,000/$18,000) and the
portion allocated to B is $5,000 ($15,000 x $6,000/$18,000).
(i) [Reserved]
(j) Additional benefits--(1) In general. If a qualified health plan
offers benefits in addition to the essential health benefits a
qualified health plan must provide under section 1302 of the Affordable
Care Act (42 U.S.C. 18022), or a State requires a qualified health plan
to cover benefits in addition to these essential health benefits, the
portion of the premium for the plan properly allocable to the
additional benefits is excluded from the monthly premiums under
paragraph (d)(1) or (d)(2) of this section.
(2) Method of allocation. The portion of the premium properly
allocable to additional benefits is determined under regulations issued
by the Secretary of Health and Human Services. See section
36B(b)(3)(D).
(k) Pediatric dental coverage--(1) In general. For purposes of
determining the amount of the monthly premium a taxpayer pays for
coverage under paragraph (d)(1) of this section, if an individual
enrolls in both a qualified health plan and a plan described in section
1311(d)(2)(B)(ii) of the Affordable Care Act (42 U.S.C.
13031(d)(2)(B)(ii)) (Affordable Care Act dental plan), the portion of
the premium for the Affordable Care Act dental plan that is properly
allocable to pediatric dental benefits that are essential benefits
required to be provided by a qualified health plan is treated as a
premium payable for the individual's qualified health plan.
(2) Method of allocation. [Reserved]
(l) Families including individuals not lawfully present--(1) In
general. If one or more individuals for whom a taxpayer is allowed a
deduction under section 151 are not lawfully present (within the
meaning of Sec. 1.36B-1(g)), the percentage a taxpayer's household
income bears to the federal poverty line for the taxpayer's family size
for purposes of determining the applicable percentage under paragraph
(g) of this section is determined by excluding individuals who are not
lawfully present from family size and by determining household income
in accordance with paragraph (l)(2) of this section.
(2) Revised household income computation--(i) Statutory method. For
purposes of paragraph (l)(1) of this section, household income is equal
to the product of the taxpayer's household income (determined without
regard to this paragraph (l)(2)) and a fraction--
(A) The numerator of which is the federal poverty line for the
taxpayer's family size determined by excluding individuals who are not
lawfully present; and
(B) The denominator of which is the federal poverty line for the
taxpayer's family size determined by including individuals who are not
lawfully present.
(ii) Comparable method. [Reserved]
Sec. 1.36B-4 Reconciling the premium tax credit with advance credit
payments.
(a) Reconciliation--(1) In general. The amount of credit allowed
under section 36B and this section is reconciled with advance credit
payments on a taxpayer's income tax return for a taxable year. A
taxpayer whose premium tax credit for the taxable year exceeds the
taxpayer's advance credit payments may receive the excess as an income
tax refund. A taxpayer whose advance credit payments for the taxable
year exceed the taxpayer's premium tax credit owes the excess as an
additional income tax liability.
(2) Credit computation. The premium assistance credit amount is
computed on the taxpayer's return using the taxpayer's household income
and family size for the taxable year. Thus, the taxpayer's contribution
amount (household income for the taxable year times the applicable
percentage) is determined using the taxpayer's household income and
family size at the end of the taxable year. If the applicable benchmark
plan changes during the taxable year, the taxpayer may be required to
use a different applicable benchmark plan to determine the premium
assistance amounts for the coverage months.
(3) Limitation on additional tax--(i) In general. The additional
tax imposed under paragraph (a)(1) of this section on a taxpayer whose
household income is less than 400 percent of the federal poverty line
is limited to the amounts provided in the table in paragraph (a)(3)(ii)
of this section (or successor tables). For taxable years beginning
after December 31, 2014, the limitation amounts may be adjusted in
published guidance of general applicability, see
[[Page 50946]]
Sec. 601.601(d)(2) of this chapter, to reflect changes in the consumer
price index.
(ii) Additional tax limitation table.
------------------------------------------------------------------------
Limitation amount
for taxpayers Limitation amount
Household income percentage of whose tax is for all other
federal poverty line determined under taxpayers
section 1(c)
------------------------------------------------------------------------
Less than 200%.................. $300 $600
At least 200% but less than 300% 750 1,500
At least 300% but less than 400% 1,250 2,500
------------------------------------------------------------------------
(4) Examples. The rules of this paragraph (a) are illustrated by
the following examples. Unless otherwise stated, in each example the
taxpayer is allowed a premium tax credit, has a calendar taxable year,
and files an income tax return for the taxable year.
Example 1. Household income increases. (i) Taxpayer A is single
and has no dependents. The Exchange in A's rating area projects A's
2014 household income to be $27,225 (250 percent of the federal
poverty line for a family of one, applicable percentage 8.05). A
enrolls in a qualified health plan. The annual premium for the
applicable benchmark plan is $5,200. A's advance credit payments are
$3,008 (benchmark plan premium of $5,200 less contribution amount of
$2,192 (projected household income of $27,225 x .0805) = $3,008).
(ii) A's household income for 2014 is $32,800, which is 301
percent of the federal poverty line for a family of one (applicable
percentage 9.5). Consequently, A's premium tax credit for 2014 is
$2,084 (benchmark plan premium of $5,200 less contribution amount of
$3,116 (household income of $32,800 x .095). Because A's advance
credit payments for 2014 are $3,008 and A's 2014 credit is $2,084, A
has excess advance payments of $924. Under paragraph (a)(1) of this
section, A's tax liability for 2014 is increased by $924.
Example 2. Household income decreases. The facts are the same as
in Example 1, except that A's actual household income for 2014 is
$21,780 (200 percent of the federal poverty line for a family of
one, applicable percentage 6.3). Consequently, A's premium tax
credit for 2014 is $3,828 ($5,200 benchmark plan premium less
contribution amount of $1,372 (household income of $21,780 x .063)).
Because A's advance credit payments for 2014 are $3,008, A is
allowed an additional credit of $820 ($3,828 less $3,008).
Example 3. Family size decreases.
(i) Taxpayers B and C are married and have two children (ages 17
and 20) whom they claim as their dependents in 2013. The Exchange in
their rating area projects their 2014 household income to be $61,460
(275 percent of the federal poverty line for a family of four,
applicable percentage 8.78). B and C enroll in a qualified health
plan for 2014 that covers the four family members. The annual
premium for the applicable benchmark plan is $14,100. B and C's
advance credit payments for 2014 are $8,704 (benchmark plan premium
of $14,100 less contribution amount of $5,396 (projected household
income of $61,460 x .0878)).
(ii) In 2014 B and C do not claim their 20-year old child as
their dependent. Consequently, B and C's family size for 2014 is
three and their household income is 332 percent of the federal
poverty line for a family of three (applicable percentage 9.5).
Their premium tax credit for 2014 is $8,261 ($14,100 benchmark plan
premium less $5,839 contribution amount (household income of $61,460
x .095)). Because B and C's advance credit payments for 2014 are
$8,704 and their 2014 credit is $8,261, B and C have excess advance
payments of $443. Under paragraph (a)(1) of this section, B and C's
tax liability for 2014 is increased by $443. Because B and C's
household income is below 400 percent of the federal poverty line,
if B and C's excess advance payments exceeded $2,500, under the
limitation of paragraph (a)(3) of this section, B and C's additional
tax liability would be limited to that amount.
Example 4. Repayment limitation does not apply. (i) Taxpayer D
is single and has no dependents. The Exchange in D's rating area
approves advance credit payments for D based on 2014 household
income of $38,115 (350 percent of the federal poverty line for a
family of one, applicable percentage 9.5). D enrolls in a qualified
health plan. The annual premium for the applicable benchmark plan is
$5,200. D's advance credit payments are $1,579 (benchmark plan
premium of $5,200 less contribution amount of $3,621 (projected
household income of $38,115 x .095) = $3,621).
(ii) D's actual household income for 2014 is $43,778, which is
402 percent of the federal poverty line for a family of one. D is
not an applicable taxpayer and may not claim a premium tax credit.
Additionally, the repayment limitation of paragraph (a)(3) of this
section does not apply. Consequently, D has excess advance payments
of $1,579 (the total amount of the advance credit payments in 2014).
Under paragraph (a)(1) of this section, D's tax liability for 2014
is increased by $1,579.
Example 5. Coverage for less than a full taxable year. (i)
Taxpayer F is single and has no dependents. In November 2013 the
Exchange in F's rating area projects F's 2014 household income to be
$27,225 (250 percent of the federal poverty line for a family of
one, applicable percentage 8.05). F enrolls in a qualified health
plan. The annual premium for the applicable benchmark plan is
$5,200. F's monthly advance credit payment is $251 (benchmark plan
premium of $5,200 less contribution amount of $2,192 (projected
household income of $27,225 x .0805) = $3,008; $3,008/12 = $251).
(ii) F begins a new job in August 2014 and is eligible for
employer-sponsored minimum essential coverage for the period
September through December 2014. F discontinues her Exchange
coverage effective November 1, 2014. F's household income for 2014
is $28,000 (257 percent of the federal poverty line for a family
size of one, applicable percentage 8.25).
(iii) Under Sec. 1.36B-3(a), F's premium assistance credit
amount is the sum of the premium assistance amounts for the coverage
months. Under Sec. 1.36B-3(c)(1)(iii), a month in which an
individual is eligible for minimum essential coverage other than
coverage in the individual market is not a coverage month. Because F
is eligible for employer-sponsored minimum essential coverage as of
September 1, only the months January through August of 2014 are
coverage months.
(iv) If F had 12 coverage months in 2014, F's premium tax credit
would be $2,890 (benchmark plan premium of $5,200 less contribution
amount of $2,310 (household income of $28,000 x .0825)). Because F
has only eight coverage months in 2014, F's credit is $1,927
($2,890/12 x 8). Because F does not discontinue her Exchange
coverage until November 1, 2014, F's advance credit payments for
2014 are $2,510 ($251 x 10). Consequently, F has excess advance
payments of $583 ($2,510 less $1,927) and F's tax liability for 2014
is increased by $583 under paragraph (a)(1) of this section.
Example 6. Changes in coverage months and applicable benchmark
plan. (i) Taxpayer E claims one dependent, F. E is eligible for
government-sponsored minimum essential coverage. E enrolls F in a
qualified health plan for 2014. The Exchange in E's rating area
projects E's 2014 household income to be $29,420 (200 percent of the
federal poverty line for a family of two, applicable percentage
6.3). The annual premium for E's applicable benchmark plan is
$5,200. E's monthly advance credit payment is $279 (benchmark plan
premium of $5,200 less contribution amount of $1,853 (projected
household income of $29,420 x .063) = $3,347; $3,347/12 = $279).
(ii) On August 1, 2014, E loses her eligibility for government-
sponsored minimum essential coverage. E cancels the qualified health
plan that covers F and enrolls in a qualified health plan that
covers E and F for August through December 2014. The annual premium
for the applicable benchmark plan is $10,000. The Exchange computes
E's monthly advance credit payments for the period September through
December as $679 (benchmark plan premium
[[Page 50947]]
of $10,000 less contribution amount of $1,853 (projected household
income of $29,420 x .063) = $8,147; $8,147/12 = $679). E's household
income for 2014 is $28,000 (190 percent of the federal poverty line,
applicable percentage 5.84).
(iii) Under Sec. 1.36B-3(c)(1), January through July of 2014
are coverage months for F and August through December are coverage
months for E and F. Under paragraph (a)(2) of this section, E must
compute her premium tax credit using the premium for the applicable
benchmark plan for each coverage month. E's premium assistance
credit amount for 2014 is the sum of the premium assistance amounts
for all coverage months. E reconciles her premium tax credit with
advance credit payments as follows:
Advance credit payments (Jan. to July)...................... $1,953
Advance credit payments (Aug. to Dec.)...................... 3,395
-----------
Total advance credit payments........................... 5,348
===========
Benchmark plan premium (Jan. to July)....................... 3,033
Benchmark plan premium (Aug. to Dec.)....................... 4,167
-----------
Total benchmark plan premium............................ 7,200
===========
Contribution amount (taxable year household income x 1,635
applicable percentage).....................................
Credit (total benchmark plan premium less required 5,565
contribution, assuming not more than premium paid).........
(iv) E's advance credit payments for 2014 are $5,348. E's
premium tax credit is $5,565. Thus, E is allowed an additional
credit of $217.
Example 7. Part-year coverage and changes in coverage months and
applicable benchmark plan. (i) The facts are the same as in Example
7, except that both E and F are eligible for government-sponsored
minimum essential coverage for January and February 2014, and E
enrolls F in a qualified health plan beginning in March 2014.
(ii) E reconciles her premium tax credit with advance credit
payments as follows:
Advance credit payments (March to July)..................... $1,395
Advance credit payments (Aug. to Dec.)...................... 3,395
-----------
Total advance credit payments........................... 4,790
===========
Benchmark plan premium (March to July)...................... 2,167
Benchmark plan premium (Aug. to Dec.)....................... 4,166
-----------
Total benchmark plan premium............................ 6,333
===========
Contribution amount for 10 coverage months (taxable year 1,363
household income x applicable percentage x 10/12)..........
Credit (total benchmark plan premium less required 4,970
contribution, assuming not more than premium paid).........
(iii) E's advance credit payments for 2014 are $4,790. E's
premium tax credit is $4,970. Thus, E is allowed an additional
credit of $180.
(b) Changes in filing status--(1) In general. A taxpayer whose
marital status changes during the taxable year computes the premium tax
credit by using the applicable benchmark plan or plans for the
taxpayer's marital status as of the first day of each coverage month.
The taxpayer's contribution amount (household income for the taxable
year times the applicable percentage) is determined using the
taxpayer's household income and family size at the end of the taxable
year.
(2) Taxpayers not married to each other at the end of the taxable
year. Taxpayers who are married (within the meaning of section 7703) to
each other during a taxable year but are not married to each other on
the last day of the taxable year, and who are enrolled in the same
qualified health plan at any time during the taxable year, must
allocate the premium for the applicable benchmark plan, the premium for
the plan in which the taxpayers enroll, and the advance credit payments
for the period the taxpayers are married during the taxable year. The
taxpayers may allocate these items to each former spouse in any
proportion but must allocate all items in the same proportion. If the
taxpayers cannot agree on an allocation, 50 percent of the premium for
the applicable benchmark plan, the premiums for the plan in which the
taxpayers enroll, and the advance credit payments for the period are
allocated to each taxpayer. If a plan covers only one of these
taxpayers for any period during a taxable year, the amounts for that
period are allocated entirely to that taxpayer.
(3) Married taxpayers filing separate tax returns. The premium tax
credit is allowed to married taxpayers only if they file joint returns.
See Sec. 1.36B-2(b)(2). Married taxpayers who receive advance credit
payments and file their income tax returns as married filing separately
have received excess advance payments. The taxpayers must allocate the
advance credit payments to each taxpayer equally for purposes of
determining their excess advance payment amounts under paragraph (a)(1)
of this section. The repayment limitation described in paragraph (a)(3)
of this section applies to each taxpayer based on the household income
and family size reported on that taxpayer's return.
(4) Examples. The following examples illustrate the provisions of
this paragraph (b). In each example, unless otherwise indicated, each
taxpayer uses a calendar taxable year and no individuals are eligible
for minimum essential coverage other than coverage in the individual
market.
Example 1. Taxpayers marry during the taxable year. (i) P is a
single taxpayer with no dependents. In 2013 the Exchange in the
rating area where P resides determines that P's 2014 household
income will be $40,000 (367 percent of the federal poverty line,
applicable percentage 9.5). P enrolls in a qualified health plan.
The premium for the applicable benchmark plan is $5,200. The
Exchange approves advance credit payments of $117 per month,
computed as follows: $5,200 benchmark plan premium minus
contribution amount of $3,800 ($40,000 x .095) equals $1,400 (total
advance credit); $1,400/12 = $117.
(ii) Q is a single taxpayer with two dependents. In 2013 the
Exchange in the rating area where Q resides determines that Q's 2014
household income will be $35,000 (189 percent of the federal poverty
line, applicable percentage 5.79). Q enrolls in a qualified health
plan. The premium for the applicable benchmark plan is $14,100. The
Exchange approves advance credit payments of $1,006 per month,
computed as follows: $14,100 benchmark plan premium minus
contribution amount of $2,027 ($35,000 x .0579) equals $12,073
(total advance credit); $12,073/12 = $1,006.
(iii) P and Q marry on June 17, 2014, and enroll in one
qualified health plan covering four family members, beginning July
1, 2014. The premium for the applicable benchmark plan is $14,100.
Based on household income of $75,000 and a family size of four (336
percent of the federal poverty line, applicable percentage 9.5), the
Exchange approves advance credit payments of $581 per month,
computed as follows: $14,100 benchmark plan premium minus
contribution amount of $7,125 ($75,000 x .095) equals $6,975 (total
advance credit); $6,975/12 = $581.
(iv) P and Q file a joint return for 2014 and report $75,000 in
household income and a family size of four. Under paragraph (b)(1)
of this section, P and Q compute their credit at reconciliation
using the premiums for the applicable benchmark plans that apply for
the months married and the months not married, and their
contribution amount based on their federal poverty line percentage
at the end of the taxable year. P and Q reconcile their premium tax
credit with advance credit payments as follows:
Advance payments for P (Jan. to June)....................... $700
Advance payments for Q (Jan. to June)....................... 6,036
Advance payments for P and Q (July to Dec.)................. 3,486
-----------
Total advance payments.................................. 10,222
===========
Benchmark plan premium for P (Jan. to June)................. 2,600
Benchmark plan premium for Q (Jan. to June)................. 7,050
[[Page 50948]]
Benchmark plan premium for P and Q (July to Dec.)........... 7,050
-----------
Total benchmark plan premium............................ 16,700
===========
Contribution amount (taxable year household income x 7,125
applicable percentage).....................................
Credit (total benchmark plan premium less required 9,575
contribution, assuming not more than premium paid).........
Additional tax.............................................. 647
(v) P's and Q's tax liability for 2014 is increased by $647
under paragraph (a)(1) of this section.
Example 2. Taxpayers divorce during the taxable year, 50 percent
allocation. (i) Taxpayers R and S are married and have two
dependents. In 2013 the Exchange in the rating area where the family
resides determines that their 2014 household income will be $76,000
(340 percent of the federal poverty line for a family of 4,
applicable percentage 9.5). R and S enroll in a qualified health
plan for 2014. The premium for the applicable benchmark plan is
$14,100. The Exchange approves advance credit payments of $573 per
month, computed as follows: $14,100 benchmark plan premium minus R
and S's contribution amount of $7,220 ($76,000 x .095) equals $6,880
(total advance credit); $6,880/12 = $573.
(ii) R and S divorce on June 17, 2014, and obtain separate
qualified health plans beginning July 1, 2014. R enrolls based on
household income of $60,000 and a family size of three (324 percent
of the federal poverty line, applicable percentage 9.5). The premium
for the applicable benchmark plan is $14,100. The Exchange approves
advance credit payments of $700 per month, computed as follows:
$14,100 benchmark plan premium minus R's contribution amount of
$5,700 ($60,000 x .095) equals $8,400 (total advance credit);
$8,400/12 = $700.
(iii) S enrolls based on household income of $16,000 and a
family size of one (147 percent of the federal poverty line,
applicable percentage 3.82). The premium for the applicable
benchmark plan is $5,200. The Exchange approves advance credit
payments of $382 per month, computed as follows: $5,200 benchmark
plan premium minus S's contribution amount of $611 ($16,000 x .0382)
equals $4,589 (total advance credit); $4,589/12 = $382. R and S do
not agree on an allocation of the premium for the applicable
benchmark plan, the premiums for the plan in which they enroll, and
the advance credit payments for the period they were married in the
taxable year.
(iv) Under paragraph (b)(1) of this section, R and S each
compute their credit at reconciliation using the premiums for the
applicable benchmark plans that apply to them for the months married
and the months not married, and contribution amount based on their
federal poverty line percentages at the end of the taxable year.
Under paragraph (b)(2) of this section, because R and S do not agree
on an allocation, R and S must equally allocate the benchmark plan
premium ($7,050) and the advance credit payments ($3,440) for the
six-month period January through June 2014 when they are married and
enrolled in the same qualified health plan. Thus, R and S each are
allocated $3,525 of the benchmark plan premium ($7,050/2) and $1,720
of the advance credit payments ($3,440/2) for January through June.
(v) R reports on his 2014 tax return $60,000 in household income
and family size of three. S reports on her 2014 tax return $16,000
in household income and family size of one. R and S reconcile their
premium tax credit with advance credit payments as follows:
R S
-------------------------------
Allocated advance payments (Jan. to $1,720 $1,720
June)..................................
Actual advance payments (July to Dec.).. 4,200 2,292
-------------------------------
Total advance payments.............. 5,920 4,012
===============================
Allocated benchmark plan premium (Jan. 3,525 3,525
to June)...............................
Actual benchmark plan premium (July to 7,050 2,600
Dec.)..................................
-------------------------------
Total benchmark plan premium........ 10,575 6,125
===============================
Contribution amount (taxable year 5,700 611
household income x applicable
percentage)............................
Credit (total benchmark plan premium 4,875 5,514
less required contribution, assuming
not more than premium paid)............
Additional credit....................... .............. 1,502
Additional tax.......................... 1,045 ..............
(vi) Under paragraph (a)(1) of this section, on their tax
returns R's tax liability is increased by $1,045 and S is allowed
$1,502 as additional credit.
Example 3. Taxpayers divorce during the taxable year, allocation
in proportion to household income. (i) The facts are the same as in
Example 2, except that R and S decide to allocate the benchmark plan
premium ($7,050) and the advance credit payments ($3,440) for
January through June 2014 in proportion to their household incomes
(79 percent and 21 percent). Thus, R is allocated $5,570 of the
benchmark plan premiums ($7,050 x .79) and $2,718 of the advance
credit payments ($3,440 x .79), and S is allocated $1,480 of the
benchmark plan premiums ($7,050 x .21) and $722 of the advance
credit payments ($3,440 x .21). R and S reconcile their premium tax
credit with advance credit payments as follows:
R S
-------------------------------
Allocated advance payments (Jan. to $2,718 $722
June)..................................
Actual advance payments (July to Dec.).. 4,200 2,292
-------------------------------
Total advance payments.............. 6,918 3,014
===============================
Allocated benchmark plan premium (Jan. 5,570 1,480
to June)...............................
Actual benchmark plan premium (July to 7,050 2,600
Dec.)..................................
-------------------------------
Total benchmark plan premium........ 12,620 4,080
===============================
Contribution amount (taxable year 5,700 611
household income x applicable
percentage)............................
Credit (total benchmark plan premium 6,920 3,469
less required contribution, assuming
not more than premium paid)............
Additional credit....................... 2 455
[[Page 50949]]
(ii) Under paragraph (a)(1) of this section, on their tax
returns R is allowed an additional credit of $2 and S is allowed an
additional credit of $455.
Example 4. Married taxpayers filing separate tax returns. (i)
Taxpayers T and U are married and have two dependents. In 2013, the
Exchange in the rating area where the family resides determines that
their 2014 household income will be $76,000 (340 percent of the
federal poverty line for a family of 4, applicable percentage 9.5).
T and U enroll in a qualified health plan for 2014. The premium for
the applicable benchmark plan is $14,100. The Exchange approves
advance credit payments of $573 per month, computed as follows:
$14,100 benchmark plan premium minus T and U's contribution amount
of $7,220 ($76,000 x .095) equals $6,880 (total advance credit);
$6,880/12 = $573.
(ii) T and U file income tax returns for 2014 using a married
filing separately filing status. T reports household income of
$60,000 and a family size of three (324 percent of the federal
poverty line). U reports household income of $16,000 and a family
size of one (147 percent of the federal poverty line).
(iii) Because T and U are married but do not file a joint return
for 2014, T and U are not applicable taxpayers and are not allowed a
premium tax credit for 2014. See Sec. 1.36B-2(b)(2). Under
paragraph (b)(3) of this section, half of the advance credit
payments ($6,880/2 = $3,440) is allocated to T and half is allocated
to U for purposes of determining their excess advance payments. The
repayment limitation described in paragraph (a)(3) of this section
applies to T and U based on the household income and family size
reported on each return. Consequently, T's tax liability for 2014 is
increased by $2,500 and U's tax liability for 2014 is increased by
$600.
Sec. 1.36B-5 Information reporting by Exchanges.
(a) Information required to be reported. An Exchange must report to
the IRS and a taxpayer the following information for a qualified health
plan the taxpayer enrolls in through the Exchange--
(1) The premium and category of coverage (such as self-only) for
the applicable benchmark plans used to compute advance credit payments
and the period coverage was in effect;
(2) The total premium for the coverage without reduction for
advance credit payments or cost sharing;
(3) The aggregate amounts of any advance credit payments or cost
sharing reductions;
(4) The name, address and taxpayer identification number (TIN) of
the primary insured and the name and TIN of each other individual
covered under the policy;
(5) All information provided to the Exchange at enrollment or
during the taxable year, including any change in circumstances,
necessary to determine eligibility for and the amount of the premium
tax credit;
(6) All information necessary to determine whether a taxpayer has
received excess advance payments; and
(7) Any other information required in published guidance of general
applicability, see Sec. 601.601(d)(2) of this chapter.
(b) Time and manner of reporting. The Commissioner may provide
rules in published guidance of general applicability, see Sec.
601.601(d)(2) of this chapter, for the time and manner of reporting
under this section.
Par. 3. Section 1.6011-8 is added to read as follows:
Sec. 1.6011-8 Requirement of income tax return for taxpayers who
claim the premium tax credit under section 36B.
(a) Requirement of return. A taxpayer who receives advance payments
of the premium tax credit under section 36B must file an income tax
return for that taxable year on or before the fifteenth day of the
fourth month following the close of the taxable year.
(b) Effective/applicability date. This section applies for taxable
years ending after December 31, 2013.
Par. 4. In Sec. 1.6012-1, paragraph (a)(2)(viii) is added to read
as follows:
Sec. 1.6012-1 Individuals required to make returns of income.
(a) * * *
(2) * * *
(viii) For rules relating to returns required of taxpayers who
receive advance payments of the premium tax credit under section 36B,
see Sec. 1.6011-8(a).
* * * * *
Steven T. Miller,
Deputy Commissioner for Services and Enforcement.
[FR Doc. 2011-20728 Filed 8-12-11; 8:45 am]
BILLING CODE 4830-01-P