On July 22, 2014 two Courts of Appeals issued decisions that address whether only people who live in states that have state-run Marketplaces (which are also called exchanges) are eligible to receive premium tax credits or subsidies under the Patient Protection and Affordable Care Act (PPACA). One court held that the subsidy should only be available to people covered by state-run Marketplaces, and the other ruled that people should be eligible for subsidies regardless what type of Marketplace their state has.
The IRS is responsible for implementing and interpreting the premium subsidies part of the law. It has ruled that all eligible individuals are entitled to a subsidy regardless whether they live in a state that has a state-run Marketplace or a federally-run Marketplace. The basic issue in these cases is whether the IRS is bound by one sentence in PPACA, which says that a taxpayer “enrolled through an exchange established by a State” is subsidy-eligible, so that only a person enrolled in a state-run Marketplace is eligible for a premium subsidy, or whether the IRS had the authority to look at PPACA as a whole and conclude that it would not make sense to limit subsidies to people in state-run Marketplaces, and therefore interpret the law to mean a person enrolled in any Marketplace is subsidy-eligible.
The Obama Administration has already said that it will appeal the decision of the Court of Appeals for the District of Columbia in Halbig v. Burwell (which ruled that the IRS overstepped its authority, and the subsidy should only be available to people living in states that have state-run Marketplaces). It is likely that the decision of the Court of Appeals for the Fourth Circuit (which ruled in King v. Burwell that the IRS has the authority to provide subsidies to individuals in all states) also will be appealed. In both of these cases a three-judge panel decided the case, so the initial appeal could be to the full Court of Appeals for that circuit. In all likelihood these cases will ultimately be appealed to the U.S. Supreme Court, which means there may not be a clear answer on this question before June 2015 or 2016.
While these cases work their way through the courts, these decisions will not be enforced. Employees who are currently receiving premium subsidies will continue to receive them. Employers in states with federally-run Marketplaces should not assume that they will not have to comply with the employer-shared responsibility (play or pay) requirements.
Certainly, a final decision that the premium subsidies are only legally available in states that have state-run Marketplaces would have a huge impact. (Currently, about one-third of the states have state-run Marketplaces and the other two-thirds have federally-run Marketplaces.) It would mean that all the people enrolled in federally-run Marketplaces who are currently receiving subsidies would no longer be eligible to receive them (it seems unlikely that subsidies that have already been received would have to be repaid). It would also mean that fewer people would be subject to the individual mandate since there is an exception to that requirement if coverage is not affordable. For employers in states with federally-run Marketplaces, penalties would not apply, because penalties are only triggered if an employee receives a subsidy. There would be broader implications as well – would so many people in the Marketplaces drop coverage because of the loss of subsidies that the Marketplaces would fail? Would states be faced with lobbying from individuals and insurers to set up a state Marketplace so that subsidies would be available, and from employers advocating for federally-run Marketplaces so that penalties would not apply?
For further information about the health care reform requirements for your business, download UBA’s complimentary guide, “PPACA Compliance and Decision Guide for Small and Large Employers” from the PPACA Resource Center at http://bit.ly/1nHbaWv.