Obamacare Individual Mandate Explained

Under the Affordable Care Act or Obamacare individual mandate, Americans are required to obtain health care insurance by 2014 or pay tax penalties. If you can’t afford to buy a health plan from private insurers, you can obtain government-approved coverage. This means paying a portion of your income to insurance companies or pay tax penalties to the federal government. Between the two, the former is a better option.

Unfortunately, not everyone can afford to buy health plans, even if it is designed for low-income earners. A lot of factors come into play, including certain conditions that are labeled as “hardships” and may qualify an individual for an exemption. Once exempted, a person and/or his dependents, can remain uninsured without incurring any fines. Of course, certain conditions must be met.

Basic Health Coverage

As a means to achieve universal coverage, Obamacare now sets the standards for health insurance rules and regulations. It dictates the minimum standards of how health plans should be sold off and on.

One of the highlights of ACA is the inclusion of essential health benefits (EHB). Even if you only buy the basic health coverage, you will have access to quality health insurance at affordable cost. EHB includes the following categories:

Ambulatory Patient Services

These refer to healthcare services that you can get without the need for hospitalization. These include but are not limited to chemotherapy, colonoscopy, biopsy, blood tests, CT scan, minor surgical procedures, radiation treatments and ultrasound imaging. Ambulatory care can be provided in a clinic, emergency room, doctor’s office or outpatient hospital department.

Emergency Services

These refer to trips in the emergency room for immediate treatment of conditions that may lead to serious disability or death. Accidents or sudden illness call for a trip to the emergency room and may include ambulance transportation. Under Obamacare, you cannot be penalized for getting treatment without prior authorization or going out of network.


These are in-patient care that you will get during your hospitalization that includes transplant, surgery, and care in a skilled nursing facility.

Maternity And Newborn Care

This cover prenatal and post-delivery care. This also includes care for newborn babies.

Mental Health And Substance Use Disorder Services, Including Behavioral Health Treatment.

Patients with mental health condition or substance abuse disorder will be evaluated, diagnosed and treated under the mental health benefits of the Affordable Care Act.

Prescription Drugs.

Drugs prescribed by doctors will be covered by your health plan, but not over-the-counter drugs even if a prescription is provided for them. Some insurers also have the option to limit the drugs they cover to only generic version if there are generics available. As for expensive drugs, coverage is possible but would need special approval.

Rehabilitative And Habilitative Services.

Rehabilitative services refer to those that will help patients recover skills, such as speech therapy following a stroke. Habilitative services, on the other hand, help develop skills, which include the use of devices that will help gain or recover physical and mental skills.

Laboratory Services.

Any testing done to help doctors diagnose an injury, condition or illness, as well as monitor the efficacy of a particular treatment falls under laboratory services. Breast cancer and prorate screenings are free of charge.

Preventive And Wellness Services And Chronic Disease Management.

These are screenings or treatments designed to prevent or detect medical conditions. Other inclusions are counseling and chronic conditions care, such as for diabetes or asthma.

Pediatric Services, Including Oral And Vision Care.

Immunizations, routine dental exams, eye exam and other infant and children care falls under pediatric services. Under Obamacare, children younger than 19 years old qualify for dental and vision care.

Tax Penalties

For each full month that you or your family is uninsured but are not exempted, you will be fined a certain amount that will have to be paid on your income tax returns. This is officially referred to as Individual Shared Responsibility Payment. In 2014, fine is 1% of your household income or $95 per adult, whichever is higher. If there are uninsured children, the fine is at $47.50. The rate of penalty changes increase year after year. 2% of the household income will be deducted from your tax refund or added to your tax bill, if you are uninsured in 2015. By 2016, the charges will increase at 2.5% of your household income. This is excluding individual calculations for uninsured adults and children, since the penalty will depend on which amount is higher.

In a year, the first three consecutive months that you’re uninsured is considered a short gap. This is often free of charge and will not be considered for penalties. Any other month that you’re uninsured after this will cost you the appropriate fines. The IRS are responsible for collecting the penalties. Normally, they are prohibited from using liens or levies to collectfines related to the healthcare act, which is why they usually deduct penalties from the refund.


Some people are allowed not to get health insurance, provided that they meet certain requirements. If you are uninsured and don’t want to be penalized, your best option would be to apply for exemption. But who are exempt from the Obamacare individual mandate?

  • Low income earners that can’t find a health plan that cost less than 8% of their total earnings.
  • People who can prove that purchasing a health plan is an “unmanageable financial burden” for them.
  • Those who have religious objections towards health insurance.
  • People who are considered unauthorized immigrants, American Indian tribe members and prisoners.
  • People who earn so low that they do not need to file a tax return.
  • Those who have one short gap.

Enrollment of Obamacare

Application for ACA should only be done during open enrollment. The open enrollment for 2015 has already ended, but special enrollment is extended to people who received a tax penalty, had a change of income, had a change of marriage status, relocated, is no longer a dependent, has lost health care coverage, and those who welcomed a new family member. Exceptional circumstances may be considered for special enrollment as well. These include unexpected hospitalizations and contract violations.

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