Learn more about ACA Pay or Play Penalties Increase for 2023 and Inflation Reduction Act Contains Health Reforms:
ACA PAY OR PLAY PENALTIES INCREASE FOR 2023
On Aug. 16, 2022, the IRS updated its FAQs
on the Affordable Care Act’s (ACA)
employer shared responsibility (pay or play)
rules to include updated penalty amounts
for 2023. The adjusted $2,000 penalty
amount is $2,880
and the adjusted $3,000
penalty amount is $4,320
.
Pay or Play Penalty Calculations
An applicable large employer (ALE) is only
liable for a penalty if at least one full-time
employee receives a subsidy for Exchange
coverage. Employees who are offered
affordable, minimum value coverage are
generally not eligible for these subsidies.
Depending on the circumstances, one of
two pay or play penalties may apply—the 4980H(a) penalty
or the 4980H(b) penalty
.
Under Section 4980H(a), an ALE will be
subject to a penalty if it does not offer
coverage to “substantially all” (generally, at
least 95%) of its full-time employees (and
dependents) and any full-time employee
receives a subsidy toward their Exchange
plan. The monthly penalty assessed under
Section 4980H(a) is equal to the ALE’s
number of full-time employees (minus 30)
multiplied by one-twelfth of $2,000 (as
adjusted) for any applicable month
.
Under Section 4980H(b), ALEs offering
coverage to substantially all full-time
employees (and dependents) may still be
subject to a penalty if at least one full-time
employee obtains an Exchange subsidy
because the ALE did not offer coverage to
all full-time employees, or the ALE’s
coverage is unaffordable or does not
provide minimum value. The monthly
penalty assessed under Section 4980H(b)
for each full-time employee who receives a
subsidy is one-twelfth of $3,000 (as
adjusted) for any applicable month
.
However, the total penalty is limited to the
4980H(a) penalty amount.
INFLATION REDUCTION ACT CONTAINS HEALTH REFORMS
On Aug. 16, 2022, President Joe Biden
signed the Inflation Reduction Act into law.
While this law is primarily aimed at fighting
inflation and reducing carbon emissions, it
also contains a number of reforms that will
impact health coverage. These reforms
have staggered effective dates and will be
implemented over the next several years.
Overview of the New Health Reforms
The health reforms primarily impact those
with Medicare coverage. Specifically, the
law implements the following measures:
• It allows the Department of Health and
Human Services to negotiate the prices
of some Medicare drugs
, effective in
2026 for 10 drugs covered by Medicare,
increasing to 20 drugs in 2029.
• Beginning in 2023, the cost of insulin
will be capped at $35 per month for
diabetics enrolled in Medicare
.
• Beginning in 2025, out-of-pocket
prescription drug costs will be capped
at $2,000 per year for Medicare
beneficiaries
.
• The law also implements a three-year
extension on increased health
insurance subsidies for coverage
purchased through an Exchange
. These
enhanced subsidies were originally
provided as part of the American Rescue
Plan Act and were set to expire at the
end of 2022.
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