74% of consumers with Affordable Care Act (ACA) health plans are happy with their coverage – but those with high deductible plans were deeply unsatisfied. The Kaiser Family Foundation’s recent report on ACA plan satisfaction holds a great deal of positive news, with some very concerning insights as well.  Overall, people are happy with their plans, have access to primary and specialty care doctors, and have a sense of financial security with their coverage.  However, 32% of those with deductibles (the amount you pay before your insurance kicks in) above $1,500 rated the value of their plan as being poor whereas only 9% of those with deductibles below $1,500 thought that of their plan’s value.  In addition, cost continues to be the main barrier to care and a large majority of second-year shoppers aren’t looking for new plans even though new high value plans may be available. Health Action NM will continue to advocate for higher value plans and inform consumers about the risks associated with high deductible plans.

- Barbara Webber, Executive Director

Health system expert Uwe Reinhardt makes an important point: when we focus our freedom to choose our health insurance carrier we sacrifice our freedom to choose our health care providers.  A recent study showed that Americans want to be able to decide what kind of health insurance is best for them.  Many debates about health care revolve around the freedom choose the health plan that you want.  And while Americans value this choice, many don’t realize that insurance carriers restrict access to many providers even as they permit access to others.  Some may remember the tragic story told by Dawnelle Keys, whose daughter died when she took her to a hospital that didn’t accept her insurance and was denied care.  If we didn’t organize our system in a way that restricted access to providers on the basis of insurance, consumers would have more opportunities to get care when they need it from the provider they choose.  This may be a conversation worth reigniting.

- Colin Baillio, Communications and Outreach

Study shows that in-person assisters play a very important role in ACA enrollment, especially those in minority populations.  A recent report by Enroll America found that consumers who received help from an assister were 60% more likely to enroll in health coverage than those who attempted online enrollment on their own. The role of in-person assisters varies by state but includes Navigators, Certified Application Counselors (CACs) and health insurance agents/brokers that all help bring greater consumer awareness of ACA health insurance coverage. The most successful assistance programs are those that work in collaboration with other state entities and utilize a nationwide assistance-scheduling tool called the Get Covered Connector. This tool works to link consumers with assisters regardless of location and streamline the enrollment assistance appointment process, as well as strengthen data monitoring and alliances with like-minded organizations. Use of in-person assisters in New Mexico is vital to enrolling hard-to-reach communities throughout the state.

- Andrea Andersen, Health Policy Intern   

Health reform is influencing physician provider practices in some interesting ways.  A collaborative initiative between aethenaResearch and the Robert Wood Johnson Foundation called ACAView closely monitored the impacts of the ACA on medical practices in 2014. They found that: 1) A feared surge of new patient volume did not occur. Although many anticipated that primary care providers would be burdened by an influx of new patients, the overall change was less than 0.3%. This lack of change may be due to continued use of urgent care clinics or emergency services by the newly insured and this was not monitored ACAView; 2) Physician offices in states that expanded Medicaid have seen sharp decreases in uninsured patients. In states that decided to expand Medicaid there was a 39% decrease in uninsured patients seen between 2013 and 2014, while those in non-expansion states only saw an 11% decline; and 3) More commercially insured patients are switching to Medicaid. Medicaid is often a better option for those in low-incomes jobs who don’t want to pay the higher out-of-pocket costs that come with private insurance.  Health Action NM is pleased that the ACA hasn’t overwhelmed doctor’s offices & hospitals and that Medicaid expansion is serving our population well.

- Andrea Andersen, Health Policy Intern   

Health Action

The White House takes action on three major consumer issues: surprise medical bills, inaccurate provider directories, and the enforcement of free birth control coverage.  1) As we reported last week, about 1/3 of those with private health insurance received surprise medical bills over the last two years.  2) According to New Mexico’s Superintendent of Insurance, inaccurate provider directories are the number one consumer complaint his office receives.  3) And a National Women’s Law Center study found that hundreds of insurance plans fail to fully cover FDA-approved contraceptives, despite the federal requirement to do so. 

The White House is working to address each of these issues administratively.  1) Next year, healthcare.gov will likely come with an out-of-pocket cost calculator that gives consumers a better idea of the overall value of their plan than, say, a premium.  The administration hopes that this will reduce unexpected costs for consumers.  2) Insurers must now update their provider directories each month, and will face a fine if they don’t.  3) New regulations clarify that insurers must cover every type of birth control without any out-of-pocket costs.

Health Action NM has been reporting on these issues to our national partners for the past year.  We are pleased to see that they are being addressed.  While progress is being made on all three of these issues, there is much more work to be done on each of them.  Health Action NM will continue to follow them closely.

- Barbara Webber, Executive Director

 

NM Medicaid expansion enrollments reach 214,000 by the end of April and are expected to grow to 241,000 by June of 2016.  The Human Services Department (HSD) announced another positive month of enrollment growth in the state’s Medicaid program.  The Medicaid expansion has been a huge success story in New Mexico.  While original estimates suggested that about 170,000 people were eligible for expanded Medicaid, we’re now expecting closer to 250,000 - the need was much greater than we anticipated.

Since the expansion began in 2014, the federal government has paid for it in full.  In 2017, the state must pick up 5% of the cost of expansion. HSD estimates that the state will need to devote about $43 million to cover these costs during fiscal year 2017.  Now is the time to start talking about how best to pay for NM’s portion of the incredibly successful Medicaid expansion.

- Joe Martinez, Outreach Coordinator

 

Employers take a new approach to reducing health costs: set your own price.  Hospitals have come under scrutiny in the past for charging exorbitant and unreasonable medical bills, driving up costs for everyone.  After one employer was charged $600,000 for a an employee’s three day stay in a local hospital, they hired a consulting firm to look in to what had happened.  The firm assessed the services and found that they cost a small fraction of what the hospital was charging.  They added a modest profit for the hospital to their calculation and sent the payment back. “We wrote a check to the hospital for $28,900 and we never heard from them again,” said the business owner.

Prices in US health care are notoriously high.  And, as this story shows, they are also extremely unreasonable.  How could a hospital get away with charging $600,000 for a procedure that they wound up accepting $28,900 for in the end?  This is why many advocates continue to push for a system where prices are transparent and set based on how much the services cost rather than backdoor deals between hospitals and insurance companies.  There is little consumers can do to stand up against this type of pricing scheme.   Isn’t it time to formally address the problem of arbitrary pricing?

- Colin Baillio, Communications and Outreach

 

Maryland implements pilot programs that may be the next big step in controlling costs for consumers.  The state is experimenting with how it pays hospitals to reduce readmissions.  It provides a lump sum of money to a hospital for any admission and doesn’t pay anything for readmissions within the next 30 days.  The hope is that hospitals will provide the best possible treatment for the patient during the first admission without providing costly and unnecessary care and will reduce the likelihood of a readmission.  Health Action NM will continue to keep an eye on this model and its impact on costs and the quality of care.

- DeAnza Sapien, JD, Health Advocacy Coordinator

Health Action

A small ACA program saves $384 million over two years.  The Affordable Care Act (ACA) created opportunities for hospitals to experiment with alternative payment models that would theoretically incentivize doctors to provide higher-quality care for lower costs.  While some were unable to do so, the Pioneer Accountable Care Organization model seems to be showing positive results: the hospitals in the program saved an average of $300 per patient, amounting to a total of $384 million over two years.  According to health journalist Sarah Kliff, “if hospitals in the Pioneer ACO program covered Medicare patients at lower-than-expected costs, they kept 70 percent of the savings in 2014 (the other 30 percent went back to the federal government). But if they spent more than expected, they would have to pay the feds back the difference.  All of a sudden, the Pioneer ACO program gave doctors a reason to spend less in a system that typically rewards anyone who spends more.”  Presbyterian Healthcare Services in New Mexico experimented with this model but has since backed out to focus on its Medicare Advantage program.  Hopefully, the ACO Pioneer model can be replicated and produce savings for consumers here in New Mexico and throughout the nation.

-          Barbara Webber, Executive Director

Consumers Union survey finds that nearly 1/3 of Americans with private health coverage were hit with surprise medical bills over the past two years.  Among those who dealt with a billing issue, only 28% were satisfied with how the issue was resolved, 75% of whom wound up having to pay the bill in full.  As we wrote about several weeks ago, states are examining how best to protect consumers from these costs.  We hope that New Mexico will begin to do so during the next legislative session.  Until then, here’s what you can do if you believe your doctor or insurance company have wrongly charged you for any service: First, file an internal appeal with your insurance company.  If your claim is denied, you can request an external review from the NM Consumer Assistance Bureau.  Note that if your employer self-insures its employees, the US Department of Labor will handle your claim.  Medicaid appeal assistance is available through Law Access NM (ABQ: 998-4529; Statewide: 1-800-340-9771).  Now is the time to start thinking about policy solutions to curb the negative outcomes of surprise medical bills.

-          Colin Baillio, Communications and Outreach

Many health plans are violating ACA standards for Essential Health Benefits (EHB) that influence women’s health. A report released this week by the National Women’s Law Center analyzed health plans in 15 states and found that many had not been adhering to Affordable Care Act’s contraceptive and maternity/newborn care benefit requirements.  Although New Mexico was not included in the report, these findings imply that issuers in other states may be following the same pattern.  These essential services are especially important for women who need access to birth control. About 99% of all women use contraceptives at some point in their lives to control when and if they become pregnant. This is extremely important considering the overwhelming data showing the age and timing of a pregnancy is highly correlated with education and employment opportunities, as well as lifetime earning capacity. New Mexico’s women deserve the right to adequate and timely access to contraceptives.  

-          Andrea Andersen, Health Policy Intern

Texas Medical Board votes to restrict use of telemedicine to remotely treat patients. When many states are making efforts to increase the availability of telemedicine, Texas has decided to take the opposite action. In mid-April of 2015, the Texas Medical Board voted to approve rules to limit the use of telephone and video technology to diagnose and treat patients remotely. This is concerning, given the serious health service access problems faced by rural areas in Texas and throughout the United States.  While patient safety is a serious concern, scaling back an important technology in a state with such great rural access needs is troubling, especially when comprehensive safety guidelines are available.  The medical board claims that the components of a successful doctor-patient relationship are not sufficiently satisfied through the use of telemedicine – but a digital doctor-patient interaction is better than no interaction. Health Action New Mexico believes that all people should have convenient access to medical advice and consultation, and supports the use of telemedicine as a device for improving this access. 

-          Ellie Perkins, Dental Health Intern

Dr. Atul Gawande says that Americans are over-tested, over-diagnosed, and over-treated. Since doctors are in an authoritative position, patients tend to trust their judgement on the best path to health.  However, sometimes less treatment is the key to reaching that goal.  “[Doctors] can recommend care of little or no value because it enhances our incomes, because it’s our habit, or because we genuinely but incorrectly believe in it, and patients will tend to follow our recommendations,” says Dr. Gawande.  The problem is that prescribing too much care is often detrimental to the patient and make care more costly for everyone.  “Our ever more sensitive technologies turn up more and more abnormalities—cancers, clogged arteries, damaged-looking knees and backs—that aren’t actually causing problems and never will. And then we doctors try to fix them, even though the result is often more harm than good.”  While well-informed consumers are key to a smart health care system, doctors play a critical role in making our system more efficient and improving treatment for patients.  Sometimes that means doing less than more.

-          DeAnza Sapien JD, Advocacy Coordinator

Health Action

 

My name is Andrea Andersen and I am the newest intern at Health Action New Mexico. I will complete my Master’s in Public Health from the University of North Carolina at Chapel Hill this winter and am very excited about being involved in the wonderful work at HANM! My main passion is helping women, children and families through access to and adequate coverage of health care services via community health work and policies.  I am a native New Mexican and understand the unique needs of our communities, so a group like HANM is a perfect fit for my interests in advocacy and equity. My interest in the maternal and child health population is grounded in a belief that strong and healthy family units, whatever they may look like, are the foundation to happy, healthy and productive communities that nourish future generations. I also have a strong interest in the connection between education and health status and I believe that policies that target this also impact the health of children in our state. This summer I will be focusing on the exploration and implementation of Certified Application Counselors and their role in increasing enrollment in the New Mexico Health Insurance Exchange (NMHIX). This is an important step in creating greater access to health care services for individuals and families throughout the state, which can ultimately lead to better health outcomes for the long-term.

Health Action

by Elizabeth Perkins
Health Policy Intern at Health Action NM

 

In a time when the term Obamacare still elicits mixed and often passionate reactions, new research suggests that shoppers are happy with their Obamacare-enable plans – even more so than those who get health coverage from an employer.  The J.D. Power 2015 Health Insurance Marketplace Exchange Shopper and Re-Enrollment (HIX) Study, released on April 23, 2015, shows a significant improvement in plan satisfaction during 2015 as compared to 2014 (the first year plans were available). Satisfaction among new members and re-enrollees that purchased plans through the marketplace exchanges created by the Affordable Care Act (ACA) is equal to or higher than with plans not purchased through an exchange.  J.D. Power reports cost to be the most significant factor influencing member satisfaction among Marketplace members.

 

As someone who has been uninsured, on Medicaid, on employer provided insurance, and having recently purchased an individual plan from the New Mexico Health Insurance Exchange (NMHIX), I like to think I offer a unique perspective on the successes and downfalls of each option. As a working adult with zero dependents it has been a long time since I have qualified for Medicaid (but I was glad the option was there when I needed it), and there are no upsides to being uninsured, so I will focus this discussion on employer provided vs Marketplace coverages.

 

When the ACA (or what many call “Obamacare”) went into effect at the end of 2013, I was working full time for a company who decided to obtain group coverage – a type of coverage that many large firms obtain.  I was excited about this decision because I was uninsured at the time and I knew the ACA required me to obtain some form of health coverage.  When I learned how much my monthly premium was going to be (and, mind you, I was only paying half, my employer paid the other half) I was shocked. I was also shocked to learn that my plan had a pre-existing condition clause!

 

Just my luck, I seriously sprained my ankle during a company softball game on the first day my plan became active. I found out about the pre-existing condition clause when I received a bill for $1200 dollars from the MRI despite having gotten a pre-authorization. I couldn’t believe that I was paying almost $200 per month (remember this is only half of the total premium) and the first time I tried to use the insurance it didn’t even pay for anything. I was irritated. Here I was, insured by a coveted employer based plan, and I was scared to use it due to the pre-existing condition clause (it only lasted 6 months, but it sure wound up costing me) and my $5,000 deductible.  But what was I going to do?  The only other option I had was the “Gold” option which would reduce my deductible to only $2,500 but nearly double my premium. I was stuck with what my employer had chosen to offer.

 

On February 18, 2015 I suddenly became unemployed, and would soon revert back to being uninsured. I was in the middle of some routine medical procedures, so I knew I needed to get coverage back sooner than later. I looked at trying to get coverage on my significant other’s insurance but the required paperwork and red tape that arose because we are not married was a lot to overcome.  So, I decided to look at the NMHIX for coverage.  I am pretty tech savvy and understand health insurance pretty well so I didn’t have much problem navigating the website, but I can see how difficult it must be for consumers who aren’t familiar with the system. However, my experience was great: I was clearly shown what financial help was available to help me pay for my premium (via a subsidy that appeared as a discount) and offered a wide range of plans ranging from $18-250 for my out-of-pocket costs.

 

I looked through the options using the website’s “compare” feature and chose a plan that I knew my current doctors would take.  It had a reasonable premium and $0 dollar deductible. What?! I didn’t believe this could be true. I was paying half of what I was paying under my employer insurance – I couldn’t  believe the plan really had no deductible (the cost that you have to pay before your insurance kicks in).

 

I decided to buy the plan and an accompanying dental plan and figured I would brace myself for when I found out what my real deductible was when I got my information packet in the mail in a few days. I received my information booklet in the mail that included a summary of benefits and my eyes focused on the section that said Deductible: $0, Out of Pocket Maximum: $2,250. I continued to read through the booklet trying to find the catch, but I found none.

 

I have only had the plan for about two months; I have used it, and encountered no issues. I have searched and searched for where the deficiency in my new Marketplace is and have so far come up empty handed; I cannot find one reason not to be satisfied with my new Obamacare plan.  Hopefully, and it seems this is so, this is the experience that other shoppers have had as well. 

Health Action

Health Action

The behavioral health shakeup continues to cripple the state’s fragile behavioral health system.  In 2013, the Martinez Administration shut down the offices of dozens of mental health providers, claiming that they fraudulently overcharged Medicaid for services.  Two years later, the administration has yet to provide evidence that the charges were fraudulent and the system remains in disarray.  The human cry now is for a roadmap forward.  Systemic reform has been attempted before several times in New Mexico.  And still, too many people, including thousands of children, are not getting the critical services they need, and they pay with the quality of their lives.  And ultimately everyone pays - not to mention the basic right to health care. Isn't it time for a well-thought-out reorganization of a system that builds on what can work?  

-       Barbara Webber, Executive Director

New York to offer more affordable coverage options to low/moderate income residents.   New York is moving forward with its Basic Health Plan, a health coverage option available to those making between 133% and 200% of the Federal  Poverty Level (FPL).  Many consumers still struggle to pay the monthly premiums offered on the private marketplace.  This new program will reduce barriers to care and reduce the “churn” between Medicaid and the exchange for people whose incomes fluctuate month-to-month.  According to the Times Union, “consumers with income at or below 150% FPL ($17,655 for a household of one, or $36,375 for a household of four) will pay no monthly premium. Those with slightly higher incomes at 200% FPL ($23,540 for a household of one, or $48,500 for a household of four) will pay $20 a month.”   

Given the state of New Mexico’s economy, it would make sense to consider this option.  State Senator Gerald Ortiz y Pino introduced a memorial to have legislative staff study the idea, but it didn’t come to a vote in the House.  Affordability remains the key barrier to accessing health coverage and care.  It’s time for New Mexico to start taking this idea seriously.

-       Colin Baillio, Communications and Outreach

New Mexico keeps its exchange but will continue to use the federal website.  Several weeks ago, the board of the New Mexico Health Insurance Exchange (NMHIX) voted to scale back funding for their IT system in order to prioritize other goals, such as providing outreach and enrollment services, marketing, and continuing the current level of staffing.  This decision was made after the federal government rejected a $90 million grant proposal drafted by NMHIX.   Without that funding, the board had to decide how to best use current funds.  Our view is that this was the best choice, given that the federal website is functional while many state websites continue to struggle.  Plus, the benefits of coordinated outreach and enrollment efforts are more important than having our own website.  After the first two years of sign-ups, we know that these services are the most effective way to inform consumers about new coverage options and help decide what kind of coverage they want.  Moving forward, outreach and enrollment assistance should be the exchange's primary tools for increasing understanding about new coverage options and enrollment numbers.

-       Joe Martinez, Consumer Outreach Coordinator

The tax season health coverage enrollment period is almost over!  Consumers who found that they owed a penalty for lacking insurance in 2014 can get covered and avoid next year’s heightened penalties.  So far, 68,000 people have taken advantage of this opportunity, which ends on April 30, 2015. Health Action New Mexico has created a bilingual consumer resource for those who want enrollment assistance during the tax enrollment period.  We hope a similar opportunity will be in place for consumers next year when the penalty increases to the greater of $625 per person or 2.5% of income.  However, more coordination needs to take place between NMHIX and tax preparers so that consumers can take advantage of the opportunity when they file taxes.  Don’t miss out on this opportunity to get covered if you are uninsured!

-       DeAnza V. Sapien, MS JD, Administration and Grant Development

 

Health Action

What Health Action NM is Reading This Week:

April 13-15

 

California’s state legislature considers extending health coverage options to undocumented immigrants. The Affordable Care Act barred undocumented immigrants from receiving Medicaid benefits, financial assistance on the exchange, and even purchasing coverage on the newly-created health insurance marketplaces.  California State Senator Ricardo Lara recently introduced a bill that would extend coverage to over a million undocumented immigrants in California by providing state funding for this population.  Communities throughout New Mexico are strengthened by families with undocumented immigrants.  And yet so many members of these families lack meaningful access to health coverage.  Is it time for New Mexico to start thinking about how to cover undocumented immigrants in our state?

• Barbara Webber, Executive Director

 

Congress passed a bill extending funding for the Children’s Health Insurance Program (CHIP). In addition to an historic effort to overhaul Medicare’s payment system, Congress has funded an essential health coverage program for kids, called CHIP, for two years.  While a four year extension would have been preferable, this deal secures protections for children that have been built in to the program that would have been under threat if the program weren’t part of this package.  Senator Udall and Senator Heinrich had the opportunity to champion a four year extension of the bill and stood in support of the measure, for which we commend them.  Health Action NM thanks all of our state’s delegation for supporting access to health care for children in New Mexico and throughout the nation.

• Colin Baillio, Communications and Outreach

 

Florida achieves remarkable health coverage outcomes by embracing a community-based outreach and enrollment model. Time and time again, we are reminded of the importance of outreach and in-person enrollment assistance.  Advocates in Florida have fully embraced this strategy, with promising results.  Despite opposition from state government, Florida “surpass[ed] enrollment projections and [achieved greater numbers than] much-larger California and even Texas, a state more populous, more uninsured and with similar Republican opposition to the law.”  Florida's model exemplifies the type of program that New Mexico must adopt to ensure that all children and families thrive.

• Joe Martinez, Consumer Outreach Coordinator

 

New York begins implementing law protecting consumers from surprise out-of-network medical bills. Private insurance plans often allow consumers to access a limited network of health care providers. These are known as “in-network providers.”  If a consumer visits a doctor who isn’t in their network, they’re usually on the hook for the full cost of the services they receive.  New York’s state legislature recognized that people are often in situations where they require emergency services outside of their insurer’s network or aren’t notified that a provider isn’t in their network.  The state passed a law to protect consumers from those unexpected costs.  

As of March 31st, “all health plans must cover at the in-network cost any out-of-network provider bill for emergency services, as well as surprise non-emergency bills for physician services in a hospital or surgical facility when an in-network provider is unavailable; the consumer was not informed in advance; or when a physician refers the consumer to any out-of-network provider,” according to the Governor's Office.  Shouldn’t New Mexico protect consumers who find themselves in a situation when they aren't aware of or able to determine whether their provider is in network?

• DeAnza Sapien, Administration and Grant Development

Health Action

The Kaiser Family Foundation recently released a report indicating that nearly half of all consumers who received tax credits in 2014 underestimated their income.  As a result, those individuals will have to pay back part or all of the additional financial assistance.  This unfortunate occurrence is a reminder that marketplace consumers should update their income on a monthly basis in order get an accurate tax credit and avoid having to pay back portions of their tax credits.

Many individuals and families don’t have a consistent month-to-month income.  Because marketplace tax credits are #question-how-do-the-premium-tax-credits-work">based on income, consumers should be sure to update their financial information on a monthly basis.  To do that, follow these instructions:   

• Online. Log in to your account. Select your existing application, choose "Report a life change" from the menu on the left, and then click on the "Report a life change" button. Find out how to upload documents
• By phone. Contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325)

Important: Do not report these changes by mail.

 

There are other factors that affect your household income for tax purposes, such as having a child or getting married.  Below is a list of life changes that should be reported to the marketplace.  Report changes if you:

• Get married or divorced
• Have a child, adopt a child, or place a child for adoption
• Have a change in income
• Get health coverage through a job or a program like Medicare or Medicaid
• Change your place of residence
• Have a change in disability status
• Gain or lose a dependent
• Become pregnant
• Experience other changes that may affect your income and household size
• Have a change in tax filing status
• Have a change of citizenship or immigration status
• Become incarcerated or released from incarceration
• Have a change in status as an American Indian/Alaska Native or tribal status
• Need to correct your name, date of birth, or Social Security number

If you have any questions regarding marketplace tax credits, please contact Health Action NM by calling (505) 322-2152 or email colin@healthactionnm.org.  

Health Action

Health Action NM has created a bilingual resource for New Mexicans who find that they owe a penalty for lacking insurance for part or all of 2014.  From March 15th to April 30th, uninsured families and individuals can sign up for health coverage with financial assistance.  The resource provides information about how to connect with in-person assistance to sign up for health coverage and avoid penalties for 2015, which increase to the greater of $325 per person or 2% of household income.   See the bottom of this page to view the resource as a JPG or click here for the PDF version.

 

Who is eligible for the “Tax Season” SEP?

Consumers are eligible for this SEP if they:

• are not currently enrolled in 2015 coverage (whether through New Mexico’s Health Insurance Exchange (NMHIX), an employer, the off-exchange individual marketplace, or other forms of minimum essential coverage),
• attest that they are or will be subject to the fee for not having health coverage for all or part of 2014 when they file their 2014 taxes, and
• attest that they first became aware of, or understood the implications of, the requirement to maintain minimum essential coverage (MEC) after the end of open enrollment (February 15, 2015) in connection with preparing their 2014 taxes.

What does “subject to the fee” mean?

• Eligible consumers must be required to pay the fee for at least part of 2014.
• Consumers do not have to have paid the fee before enrolling through the SEP. In other words, consumers who have not yet filed their 2014 income tax return (including those who have an IRS extension to file their 2014 return) may still be eligible for this SEP so long as they will have to pay the fee when they do actually file their taxes.

Who is not eligible for this SEP?

• Consumers who are exempt from the fee for the entire year in 2014 or who had coverage for the entire year in 2014.
• Consumers who completed their tax filing prior to February 15, 2015 or otherwise became aware that they would be subject to the fee in 2014 before the end of open enrollment.
• Consumers who do not have to pay the penalty but are subject to reconciliation and have to repay Advance Premium Tax Credits received in 2014.

How long does this SEP last?

• This SEP will begin on March 15th and end on April 30th.
• Consumers who qualify must complete the entire enrollment process (that is, including selecting a plan) by 11:59 pm E.S.T. on April 30th.
• Similar to during open enrollment, consumers who enroll in an initial plan during this SEP can switch to a different plan through April 30th. Note, however, that all plan selections and enrollment processes must be completed by 11:59 pm E.S.T. on April 30th.

How will eligible consumers open or unlock this SEP?

• As of March 15th, the online application includes questions about the attestations in the third and fourth eligibility requirements listed above. 
• Consumers can also access this SEP through the Call Center.

When will coverage begin?

• Normal coverage effective dates apply. If a consumer enrolls in coverage on or before the 15th of the month, coverage will be effective on the first day of the following month. In order to have coverage begin April 1st, consumers must enroll on March 15th.
• Note that consumers who enroll through this SEP will be subject to the fee for the months they did not have coverage and were not exempt in 2015 when they file their taxes in 2016. For example, if an eligible consumer enrolls on March 15th his coverage will begin April 1st. When he files his 2015 taxes in 2016, he will be subject to the fee for January through March (3 months) unless he qualifies for an exemption.

Are undocumented immigrants or Native Americans subject to the shared responsibility payment if they don’t have health coverage?

Undocumented immigrants and Native Americans do not have to pay any fees or penalties for lacking health coverage.  The IRS recently clarified this rule, stating “Individuals who are not U.S. citizens or nationals, and are not lawfully present in the United States, are exempt from the individual shared responsibility provision and do not need to make a payment.  For this purpose, an immigrant with Deferred Action for Childhood Arrivals (DACA) status is considered not lawfully present and therefore is exempt.  An individual may qualify for this exemption even if he or she has a social security number (SSN).”

If an improper penalty has been charged, tax filers will need to amend their tax return by filling out Form 8965, which can be found at http://www.irs.gov/pub/irs-pdf/f8965.pdf.

 

 ENGLISH VERSION

Health Action