Quote-of-the-day mailing list
-------- Original Message --------
Subject: qotd: Hardship? No penalty, but no insurance
Date: Mon, 1 Jul 2013 09:01:30 -0700
From: Don McCanne <email@example.com>
To: Quote-of-the-Day <firstname.lastname@example.org>
Centers for Medicare and Medicaid Services
June 26, 2013
Guidance on Hardship Exemption Criteria and Special Enrollment Periods
The Department of Health and Human Services (HHS) finalized provisions
concerning how Marketplaces (also known as "Exchanges") will determine
eligibility for and grant certificates of exemption from the individual
shared responsibility payment described in section 5000A of the Internal
This guidance is intended to describe the circumstances that
Marketplaces may use in determining what constitutes a hardship if they
prevent an individual from obtaining coverage under a QHP.
We clarify that Marketplaces may consider the following circumstances in
determining what constitutes a hardship under 45 CFR 155.605(g)(1) if
they prevent an individual from obtaining coverage under a QHP, which
include an individual who--
* becomes homeless;
* has been evicted in the past six months, or is facing eviction or
* has received a shut-off notice from a utility company;
* recently experienced domestic violence;
* recently experienced the death of a close family member;
* recently experienced a fire, flood, or other natural or human-caused
disaster that resulted in substantial damage to the individual's property;
* filed for bankruptcy in the last 6 months;
* incurred unreimbursed medical expenses in the last 24 months that
resulted in substantial debt;
* experienced unexpected increases in essential expenses due to caring
for an ill, disabled, or aging family member;
* is a child who has been determined ineligible for Medicaid and CHIP,
and for whom a party other than the party who expects to claim him or
her as a tax dependent is required by court order to provide medical
support. We note that this exemption should only be provided for the
months during which the medical support order is in effect; or
* as a result of an eligibility appeals decision, is determined eligible
for enrollment in a QHP through the Marketplace, advance payments of the
premium tax credit, or cost-sharing reductions for a period of time
during which he or she was not enrolled in a QHP through the
Marketplace, noting that this exemption should only be provided for the
period of time affected by the appeals decision.
Comment: The Affordable Care Act (ACA) requires that individuals who
fail to enroll in a qualified health plan (QHP) be required to make a
shared responsibility payment (a financial penalty for being uninsured).
There are several exemptions that allow the penalty to be waived, and
one of these is "individuals who experience a hardship." This guidance
defines what constitutes a hardship.
Supposedly a goal of health care reform was to be sure that everyone had
health care coverage, but especially those whose personal finances made
purchase of insurance prohibitive. That is why the most important
provisions of ACA included the expansion of Medicaid for individuals at
or near poverty and the establishment of income adjusted subsidies for
purchase of private plans within the insurance exchanges (Marketplace).
The shared responsibility payment penalty was established to encourage
those who could afford insurance to buy it, with a goal of approaching
truly universal coverage.
When it was realized that there were many legitimate situations in which
individuals would not qualify for either Medicaid or the subsidies for
the exchange plans and yet could not afford to purchase plans, it was
thought that it would be unfair to penalize these individuals for being
uninsured, as if that were not enough of a penalty. Thus the exemptions
from the penalty were established.
Of the exemptions, hardship is perhaps the most compelling. But think
about that. These are individuals who have the greatest need to have the
security of health care coverage, yet, instead of establishing measures
that would bring them under the insurance umbrella, they are being left
bare - exposed to greater financial hardship and greater barriers to
health care access.
Is this the best that we can do for these people - waive a financial
penalty for the sin of being uninsured - a penalty that they couldn't
Absolutely everyone should be covered - automatically. How many times do
we have to say it? Single payer.