Frequently Asked Questions

The "Patient Protection and Affordable Care Act," commonly known as PPACA, was first introduced as a measure to deal with rising healthcare costs and numbers of uninsured.

The heart of PPACA consists of three provisions: guaranteed issue (insurers must offer coverage regardless of the applicant's health status or pre-existing conditions), community rating (insurers must offer policies within a given territory at the same price regardless of health status, age, gender, or other factors), and an individual mandate. The individual mandate assures that everyone has a minimum amount of coverage: those above a certain annual income are required to purchase coverage or incur a tax penalty; those who cannot afford it will have their coverage paid for by the government.

As PPACA continues to be implemented and challenged throughout the country, understanding the issues and implications for the international insurance industry and your business becomes all the more important.

Tax Calculations

Taxes begin in 2014 and rise in years following. In each year, the tax consists of the higher of a dollar amount or a percentage of household income. For a given household, the tax applies to each individual, up to a maximum of three. Following is the schedule of taxes:

• 2014: The higher of $95 per person (up to 3 people, or $285) OR 1.0% of taxable income.
• 2015: The higher of $325 per person (up to 3 people, or $975) OR 2.0% of taxable income.
• 2016: The higher of $695 per person (up to 3 people, or $2,085) OR 2.5% of taxable income.
• After 2016: The same as 2016, but adjusted annually for cost-of-living increases.

Tax Examples

2014 - family of 2; taxable income = $26,000;
tax = $260 because $260 ($26,000 x 1%) is higher than $190 ($95 x 2 persons).

2014 - family of 3; taxable income = $26,000;
tax = $285 because $285 ($95 x 3 persons) is higher than $260 ($26,000 x 1%).

Under PPACA, all U.S. citizens, nationals and resident aliens will be required to purchase minimum essential coverage (PPACA compliant coverage), unless they are exempt.

IMG’s Global Medical Insurance Plan does not meet the definition of “minimum essential coverage” under PPACA. While your GMI plan for worldwide coverage will not be affected by PPACA, you should review the information below to see if you are exempt from the requirements of PPACA or not, and whether you will have to pay a tax penalty or not.

The IRS provides a questions and answers page on the individual mandate. Question 11 asks whether all individuals living in the U.S. are subject to the mandate. The answer is that U.S. citizens and permanent legal residents are subject to the mandate, as are “foreign nationals who are in the U.S. long enough during a calendar year to qualify as resident aliens for tax purposes.” Thus, non-resident aliens are not subject to the individual mandate, even if they have to file a tax return.

Am I a Resident or Non-Resident Alien?

The IRS states that you are a non-resident alien unless you meet either the green card test or the substantial presence test.

According to IRS Publication 519, Tax Guide for Aliens, under the green card test, green card holders are resident aliens for tax purposes. The substantial presence test uses a formula to count the number of days present in the U.S. over the past 3 years. Generally, you are a resident alien after six months of presence in the U.S. – unless you are exempt.

Exempt non-U.S. citizens include:

• A non-U.S. citizen who is not a permanent legal resident (the green card test) or has not been in the U.S. for 183 days over the last three year period.
• A non-U.S. citizen temporarily present in the United States as a foreign government-related individual under an “A” or “G” visa.
• A non-U.S. citizen teacher or trainee temporarily present in the United States under a “J” or “Q” visa.
• A non-U.S. citizen student temporarily present in the United States under an “F,” “J,” “M,” or “Q” visa.
• A non-U.S. citizen professional athlete temporarily in the United States to compete in a charitable sports event; and
• Expatriate employees living outside of their home countries for six months or more of a year.
• A person who is required to, but does not have minimum essential coverage for up to three months during the year (only one three-month period allowed each year).

Here are some Alien Residence examples to assist you.

IMG’s international travel medical products are not a substitute for minimum essential coverage that you may need to have under PPACA. If you are a U.S. citizen, national or legal resident alien in the U.S., you will need to maintain minimum essential coverage unless you are exempt. Exemptions include:

• Individuals not residing in the U.S.
• Non-U.S. citizens who are “non-resident aliens” (for U.S. income tax purposes).  See Am I a Resident or Non-Resident Alien? 
• Individuals with a coverage gap of less than 3 months
• Individuals who cannot afford coverage (i.e. required contribution exceeds 8% of household income)
• Individuals with a religious conscience exemption (applies only to certain faiths)
• Members of a health care sharing ministry
• Incarcerated individuals
• Individuals with income below the tax filing threshold; and
• Members of Indian tribes

You will not need PPACA coverage for short-term travel to the U.S., unless you are considered an “alien lawfully present” in the U.S. See I am a Non-U.S. citizen covered under a Global Medical Insurance Plan.

In general, PPACA does not govern short-term limited duration insurance, like IMG’s short-term travel medical insurance programs.

However please understand that under PPACA, as of January 1, 2014, extensions of short-term coverage will be limited to less than 12 months to meet the definition of a short-term limited duration plan.

IMG’s international travel medical products are not a substitute for minimum essential coverage that you may need to have under PPACA. However, since most PPACA plans do not provide the types of international benefits and assistance that travelers need, you should strongly consider purchasing an international travel medical plan such as IMG’s Patriot Lite Travel Medical Insurance for coverage while you travel outside of the U.S.

If you are a U.S. citizen, national or an “alien lawfully present” in the U.S., you will need to maintain minimum essential coverage unless you are exempt. Exemptions include:

• Individuals not residing in the U.S.
• Non-U.S. citizens who are “non-resident aliens” (for U.S. income tax purposes). See Am I a Resident or Non-Resident Alien?
• Individuals with a coverage gap of less than 3 months.
• Individuals who cannot afford coverage (i.e. required contribution exceeds 8% of
• household income).
• Individuals with a religious conscience exemption (applies only to certain faiths).
• Members of a health care sharing ministry.
• Incarcerated individuals.
• Individuals with income below the tax filing threshold; and
• Members of Indian tribes

In general, PPACA does not govern short-term limited duration insurance, like IMG’s short-term travel medical insurance programs.

However, please understand that under PPACA, as of January 1, 2014, extensions of short-term coverage will be limited to less than 12 months to meet the definition of a short-term limited duration plan.

As non-resident aliens, international students on F, J, M and Q visas (and certain family members of students) are not subject to the individual mandate for their first 5 years in the U.S. All other J categories (teacher, trainee, work and travel, au pair, high school, etc.) are not subject to the individual mandate for 2 years (out of the past six).

Since international students are not subject to the mandate, they are not required to purchase a plan that meets PPACA requirements and can purchase an appropriate IMG plan.

International Students – Exempt as Non-Resident Aliens

Under the IRS international student exemption, anyone “temporarily in the United States on an “F”, “J”, “M”, or “Q” visa for the primary purpose of studying at an accredited academic institution or vocational school (and certain family members of students), and who substantially complies with the requirements of that visa,” is exempt from being treated as a resident alien, and is therefore exempt from the individual mandate as a non-resident alien.

That exemption applies for 5 years. After 5 years, a student is no longer exempt, and the substantial presence test must be applied. See examples here.

Even after 5 years in the U.S., an international student may continue to be a non-resident alien for tax purposes under the “Closer Connection” exception if they can prove that they still have a closer connection to their home country than to the U.S.

The Individual Mandate and Alien / Non-Alien Status

The IRS provides a questions and answers page on the individual mandate. Question 11 asks whether all individuals living in the U.S. are subject to the mandate. The answer is that U.S. citizens and permanent legal residents are subject to the mandate, as are “foreign nationals who are in the U.S. long enough during a calendar year to qualify as resident aliens for tax purposes.” Thus, non-resident aliens are not subject to the individual mandate, even if they have to file a tax return.

Am I a Resident or Non-Resident Alien?

The IRS states that you are a non-resident alien unless you meet either the green card test or the substantial presence test.

Under IRS Publication 519, Tax Guide for Aliens (the green card test), green card holders are resident aliens for tax purposes. The substantial presence test uses a formula to count the number of days present in the U.S. over the past 3 years. Generally, you a resident alien after six months of presence in the U.S. – unless you are exempt.

"Expatriate health plans" are defined as a group health plan or health insurance coverage offered in connection with a group health plan meeting all of the following:

1. Substantially all of the primary enrollees are "qualified expatriates" (see below). Primary enrollees do not include individuals who are not U.S. nationals residing in the country of their citizenship;
2. Substantially all of the benefits provided by the plan are not excepted benefits (e.g., not limited-scope dental/vision, health FSA, fixed indemnity);
3. The plan provides coverage for inpatient hospital services, outpatient facility services, physician services, and emergency services;
4. The plan sponsor reasonably believes that the plan’s benefits provide minimum value (i.e., the percentage of the total allowed costs of benefits provided under the plan is no less than 60 percent);
5. If the plan provides dependent children coverage, such coverage is available until the adult child turns age 26;
6. The plan is administered by an administrator that has licenses to sell insurance in more than two countries, maintains a number of related international standards specified in the law, and offers reimbursement for items or services in the local currency in eight or more countries; and
7. The plan satisfies a number of coverage requirements set forth in the Public Health Service Act (PHSA), Internal Revenue Code, and ERISA, other than those added by the ACA (e.g., NMHPA, MHPAEA, WHCRA, Michelle’s law).

This definition includes both fully insured and self-insured plans. Prior transitional relief had applied only to insured expatriate plans.

To qualify as an “expatriate health plan,” substantially all of the primary enrollees must be “qualified expatriates.” A “qualified expatriate” is a primary insured meeting all of the following:

Qualified Expatriates in the U.S.:

The individual’s skills, qualification, job duties, or expertise is of a type that has caused the employer to assign him to the U.S. for a specific temporary purpose or assignment tied to employment; and

In connection with such transfer or assignment, the plan sponsor reasonably determines that the individual will require access to health insurance in multiple countries, and is offered other multi-national benefits on a periodic basis (e.g., tax equalization benefits, cross-border moving expenses, compensation to enable the expatriate to return to his home country);

Qualified Expatriates Outside of the U.S.:

The individual is working outside the U.S. for a period of at least 180 days in a consecutive 12-month period that overlaps with the plan year. For purposes of the definition, “U.S.” includes the 50 states, D.C., and Puerto Rico.

There are also special provisions for members 501(c)(3) and 501(c)(4) organizations who are traveling or relocating internationally for the organization, including students and religious missionaries.

Expatriate Health Plans are Minimum Essential Coverage

Expatriate health plans qualify as minimum essential coverage. This means that an expatriate health plan will satisfy the employer mandate and the enrollee’s individual mandate.

Employers are Still Subject to §6055/§6056 Reporting and Cadillac Tax on Certain Expatriates

The exemption from ACA requirements does not apply for the new health information reporting requirements for the beginning of 2016.

However, the information statements (primarily the Forms 1094-C and 1095-C for employers) may be provided electronically to individuals covered under an expatriate health plan even if the individual has not consented to electronic distribution (as long as the individual has not explicitly refused electronic distribution).

Expatriate health plans will be exempt from the §4980I excise tax on high cost employer-sponsored health coverage (generally referred to as the “Cadillac tax”) that is scheduled to take effect in 2018, except for expatriates assigned to work in the U.S.

Effective Date

These provisions related to expatriate health plans apply to expatriate health plans issued or renewed on or after July 1, 2015.

No. Under PPACA, the term “health insurance coverage” means insurance benefits offered by a “health insurance issuer,” which is an insurance company that is licensed to engage in the business of insurance in a State of the U.S. and which is subject to State law that regulates insurance. IMG’s international plans are underwritten by Sirius International Insurance Corporation, a Swedish insurance company, for persons that are not eligible for or required to purchase a PPACA plan. If you are now eligible for or required to purchase a PPACA plan and the PPACA plan application asks you whether you currently have “health insurance coverage,” you should answer that question “No.”