# Affordable Care Act and Expats



## FHBOY

If we can leave behind all the politics of this, there is a good question to be asked:

How does the ACA affect those USA citizens living abroad as expats who are not yet old enough for Medicare (yes, some of us are that young). We are, after all, USA citizens. 

I would appreciate links and citations, rather than opinions.

I left the USA as a Maryland resident and now wonder if we would be required to sign up for USA based health insurance through an exchange or face the tax penalty under the law.


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## AlanMexicali

FHBOY said:


> If we can leave behind all the politics of this, there is a good question to be asked:
> 
> How does the ACA affect those USA citizens living abroad as expats who are not yet old enough for Medicare (yes, some of us are that young). We are, after all, USA citizens.
> 
> I would appreciate links and citations, rather than opinions.
> 
> I left the USA as a Maryland resident and now wonder if we would be required to sign up for USA based health insurance through an exchange or face the tax penalty under the law.


The tax penalty for 2014 for not having heath insurance is about $60.00 US and not until 2016 will it be $600.00 US. We have a couple of years more to get medicare. I have a Calif. residence so I am presuming it will apply to me. No US residence and I presume it will not apply. I don´t know for sure.


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## vantexan

AlanMexicali said:


> The tax penalty for 2014 for not having heath insurance is about $60.00 US and not until 2016 will it be $600.00 US. We have a couple of years more to get medicare. I have a Calif. residence so I am presuming it will apply to me. No US residence and I presume it will not apply. I don´t know for sure.


It's $95 per person in the household in 2014, will be $695 per person in 2016. I believe there was a recent thread and the question was do you have to be a legal resident in another country for 330 out of the 365 days in a calendar year or do you just have to be out of the country 330 days to avoid carrying insurance or paying the penalty?


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## RVGRINGO

Just send a copy of your Residente Permanente card; that should do it.


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## Newyorkaise

BBCWatcher (whose posts are generally thoughtful and well-reasoned) has provided a detailed description of the ACA over on the USA forum. On the question of non-residents, the post says:

"If you are not a resident of any of the 50 U.S. states or of the District of Columbia then you are not subject to the new health insurance requirements in the PPACA. (For purposes of determining whether or not you will owe a penalty if you do not have adequate health insurance, the IRS will generally look at whether or not you could qualify for the Foreign Earned Income Exclusion -- regardless of whether you actually take the FEIE. Residents of Puerto Rico, the U.S. Virgin Islands, Guam, and other parts of the U.S. outside the 50 states and D.C. are not subject to the PPACA.)"

This certainly sounds like a reasonable approach by the IRS, and it sounds as if the key is actual legal residency elsewhere. Still, there's no specific citation given. If I run across anything more definitive, I'll stop back here and let you know.

One small thing: you mention Medicare for the over-65 set, but insofar as I am aware, original Medicare doesn't cover anyone living abroad (although there may be some private supplemental plans that do). I believe there have been rumblings about doing pilot programs in Canada and Mexico, but I don't know that they have come to anything as yet (alas!).


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## joaquinx

Questions and Answers on the Individual Shared Responsibility Provision Read paragraph 12.


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## FHBOY

Newyorkaise said:


> One small thing: you mention Medicare for the over-65 set, but insofar as I am aware, original Medicare doesn't cover anyone living abroad (although there may be some private supplemental plans that do). I believe there have been rumblings about doing pilot programs in Canada and Mexico, but I don't know that they have come to anything as yet (alas!).


My bad, I was referring to when we go back to the USA and need (God forbid) medical care, not when we are living as expats. I know that Medicare is NG in Mexico, and the issue there is whether or not to opt for Medicare coverage as a full time expat (a totally different topic).


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## Hound Dog

We are now respecitvely 71 and 67 having been retired in Mexico since 2001 and fully eligible for Medicare . We have elected to dissasociate ourselves from Medicare in every sense and fullly insure for major medical coverage through an international insurance company but here is the kicker. Even if that insurance company screws us to the wall and refuses any major medical claims we may put forth in the future, we would a thousand times rather opt for major medical treatment in Mexico than the U.S. for two reasons and maybe more:
* Here we will be treated as human beings in private accomodations by, in our experience, over the past 13 years compassionate and highly competent physicians and hospital staff at a mere fraction of the cost we would incur in the United States.
* Here, we don´t have to sign up with disgruntled doctors and staff treating us as worms in a coffee can. When we sought the care of physicians under our HMO Kaiser Permanente in Northern California in the 1990s, we never saw the same physician two times in a row and were nothing more than numbers on a chart immediately forgotten. A disgraceful system treating the poor and middle class as cockroaches disturbing the tranquliity of the household.

Down here over the past decade plus, I have received the best medical and dental treatment of my life at a fraction of the cost imposed in San Francsco. Choose your arena but if that is the United States, bring a fat wallet and a cynical state of mind.


r


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## Longford

That some disgruntled persons fled or were ejected from the USA , or any other country of their origin, and then who freely choose to disassociate themselves from the benefits they either earned or were entitled to in their home country ... is fine with me. Let the country they fled to, fear in hand, welcome and care for them. Freedom of choice. It's wonderful. Isn't it?


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## Hound Dog

_


Longford said:



That some disgruntled persons fled or were ejected from the USA , or any other country of their origin, and then who freely choose to disassociate themselves from the benefits they either earned or were entitled to in their home country ... is fine with me. Let the country they fled to, fear in hand, welcome and care for them. Freedom of choice. It's wonderful. Isn't it?

Click to expand...

_
I have no idea to whom you are referring, Longford, but since that snotty remark followed my post, let me tell you that my wife and I are citizens of the United States and France respectively, permanent residents of Mexico, have lived here as retirees for 13 years full-time, and will soon be Mexican citizens and we pay our own way here for all things including medical care, housing, food and transportation , peso for peso. We leech off of no one _*ever*_ but are damned pleased that we can enjoy the protection of the Mexican medical establishment which is reasonably priced and much superior in practice in places such as Guadalajara to places such as San Francisco where we lived for 40 years and, no doubt, Chicago. The medical establishment in the United States is a disgrace. In France, on the other hand, if one has had a career working there, total medical costs are free and the medical care is excellent. In Mexico, it is not necessarily free but iinexpensive and a hell of a lot more efficacious and more civilly administered than in the dreaded U.S. system. Down here you actually can find a doctor who remembers who the hell you are and may even recall your infirmities. At that HMO in San Francisco there were two things you could depend on. You woulld be assigned the next two-bit doctor available who couldn´t succeed in private practice and he/she would allot you 10 minutes or be financially penalized.

I wouldn´t move back to the U.S. if they threw free medical care at me and promised me a cherry snowcone as I reposed there in that dormitory room with 300 other ward inhabitants waiting to kick the bucket.


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## lagoloo

Fact: if you don't have a U.S. address, you don't have to pay for the new "Obamacare" health insurance. Point being, that if you are an expatriate, you don't pay. Now, about those people who want to have it both ways, I have no comment.


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## vantexan

lagoloo said:


> Fact: if you don't have a U.S. address, you don't have to pay for the new "Obamacare" health insurance. Point being, that if you are an expatriate, you don't pay. Now, about those people who want to have it both ways, I have no comment.


You may not have a U.S. address but if you choose to spend more than 35 days in the U.S. in a 12 month period you will be on the hook to pay.


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## Longford

Hound Dog said:


> I wouldn´t move back to the U.S. if they threw free medical care at me and promised me a cherry snowcone as I reposed there in that dormitory room with 300 other ward inhabitants waiting to kick the bucket.


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## FHBOY

Friends:
While I appreciate the lively give and take, with accompanying illustrations of my hero, I was more interested in the one post which said as a Permanente or even a Temporada with no USA address (other than my mailbox in TX), we will not be subject to the ACA tax. I would appreciate more factual info.

As to the state of health care: USA vs. Mexico, I'll leave that to others. Fortunately, in my nine months here, I've not had an occasion to get deeply involved in that here. I do have a doctor who charges me $200p for a visit, had a dental cleaning for $150p, and am very happy. 

Meds, while readily available without prescription have prven not to be the "bargain" I thought they'd be, the prices are, yes, cheaper, but the quantities at the prices are far less than the 90-day quantities we are used to in the USA, but it is less expensive but not that much. One med I have given up would be less expensive than my pre-insurance costs in the USA, but not by much. Named USA drugs here, that do not have Mexican produced counterparts are not such a great bargain. Fortunately the drug is not critical to my day-to-day health any longer!  

As a side note: I carry only universal catastrophic health coverage for us ($900 USD/year) thru Best Doctors. It does have a $5K USD deductible, which we will cover from a de facto HSA in the USA, but I am relatively healthy and live, so far, a very "non-risk low key" life. Anecdotal: my friend tells me of his wife's stay in a hospital for a hip replacement cost, in toto, less than $6K USD. That is amazing!

So, more facts on ACA and stay healthy!


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## lagoloo

With a little patience and web-searching, you can find the paragraph in a government site which clearly states that permanent expats are exempt from "Obamacare" . It is only applicable to residents of the U.S.

FHBoy asked the same question on the local Chapala web board and it was answered.:bolt:
__________________________________________________________________________
"Found this on one of the government sites: (HEALTHCARE.GOV.) Start the search with "exemptions for..............etc." you'll find the site.

"U.S. citizens living outside the U.S.

U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay."
________________________________________________________________________


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## vantexan

lagoloo said:


> With a little patience and web-searching, you can find the paragraph in a government site which clearly states that permanent expats are exempt from "Obamacare" . It is only applicable to residents of the U.S.
> 
> FHBoy asked the same question on the local Chapala web board and it was answered.:bolt:
> __________________________________________________________________________
> "Found this on one of the government sites: (HEALTHCARE.GOV.) Start the search with "exemptions for..............etc." you'll find the site.
> 
> "U.S. citizens living outside the U.S.
> 
> U.S. citizens living in a foreign country are not required to get health insurance coverage under the Affordable Care Act. If you're uninsured and living abroad, you don't have to pay the fee that other uninsured U.S. citizens may have to pay."
> ________________________________________________________________________


Yes but they define living abroad as 330 days or more outside of the U.S. in a 12 month period. For example say you sell everything in the U.S. and move to Ajijic. No U.S. address. But you enjoy spending summers with your adult children in California. By the gov't's reckoning you must maintain acceptable insurance in the U.S. or be penalized.


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## lagoloo

vantexan said:


> You may not have a U.S. address but if you choose to spend more than 35 days in the U.S. in a 12 month period you will be on the hook to pay.


Please cite your source.

For those who are Permanent residents ........I have my doubts.


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## vantexan

lagoloo said:


> Please cite your source.
> 
> For those who are Permanent residents ........I have my doubts.


I googled Obamacare living overseas and got numerous hits. If you are, as they put it, a bona fide resident of another country that counts too. But you have to prove that, they don't just take your word. Or you can be out of the country for 330 days or more and they presume you meet the minimum standards with no further action required.


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## Longford

vantexan said:


> I googled Obamacare living overseas and got numerous hits. If you are, as they put it, a bona fide resident of another country that counts too. But you have to prove that, they don't just take your word. Or you can be out of the country for 330 days or more and they presume you meet the minimum standards with no further action required.


Forum rules prohibit linking to other expat forums, so I'll just mention that there's a popular website with a forum for expats which focuses on the Yucatan and where there's been an excellent discussion, for the past year, regarding the Affordable Care Act and it's impact on expats. Google "Yucatan forums" or other such words and the website will probably be listed and you can then see the discussion. The moderator/owner of that site seems always to be well informed.


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## RVGRINGO

As one who has had two very serious hospitalizations this year, in Guadalajara, and who is now in end-stage congestive heart failure, unable to do much beyond sit and suck oxygen, I can add to the praise for those who have cared for me, and who continue to do so. In fact, my cardiologist just called me yesterday to have my wife stop by and pick up a pile of samples, and to schedule an echocardiogram locally. He was also instrumental in my recent escape from the hospital at a reduced co-pay. The care in two separate hospitals this year was excellent and the nurses and others were always cheerful and attentive. I even enjoyed the food. I owe what little time I have left to my gastroenterologist and cardiologist; both of whom are genuinely nice guys, who really care about the well-being of their patients, even to the palliative care toward the end.
So, if I suddenly go silent, you will know what happened. Meanwhile, I am just increasingly fuzzy and making more typos than in the past.


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## vantexan

Longford said:


> Forum rules prohibit linking to other expat forums, so I'll just mention that there's a popular website with a forum for expats which focuses on the Yucatan and where there's been an excellent discussion, for the past year, regarding the Affordable Care Act and it's impact on expats. Google "Yucatan forums" or other such words and the website will probably be listed and you can then see the discussion. The moderator/owner of that site seems always to be well informed.


That forum was actually one of the threads that turned up on Google. Very informative.


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## TundraGreen

RVGRINGO said:


> As one who has had two very serious hospitalizations this year, in Guadalajara, and who is now in end-stage congestive heart failure, unable to do much beyond sit and suck oxygen, I can add to the praise for those who have cared for me, and who continue to do so. In fact, my cardiologist just called me yesterday to have my wife stop by and pick up a pile of samples, and to schedule an echocardiogram locally. He was also instrumental in my recent escape from the hospital at a reduced co-pay. The care in two separate hospitals this year was excellent and the nurses and others were always cheerful and attentive. I even enjoyed the food. I owe what little time I have left to my gastroenterologist and cardiologist; both of whom are genuinely nice guys, who really care about the well-being of their patients, even to the palliative care toward the end.
> So, if I suddenly go silent, you will know what happened. Meanwhile, I am just increasingly fuzzy and making more typos than in the past.


I am amazed by your upbeat attitude in the face of some very unpleasant conditions. I will happily tolerate your typos.


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## Hound Dog

RV:

I am sorry to here about you ailments and wish you the best of luck. I believe I understand your quandary. Your post gives me an opportunity to talk about health care alternatives based on an incident in my life in December, 2008 when we were resident in our home in San Cristóbal de Las Casas rather than our home in Ajijic. Most who post or read here know that the medical care and hospital facilities are quite superior in Guadalajara but many may not know that the medical care and hospital facilities in Chiapas in general, even including the state capital of Tuxtla Gutierrez, are, at best substandard. Anyway, there I was in San Cristóbal having an ordinary dinner when my appetite tanked and I could no longer eat and that condition quickly worsened into true sickness which turned out to be the need for emergency gall bladder removal or death within hours. The insurance company informed me that they would fly me for free to Mexico City, Guadajara or Monterrey for expert surgical medical care but this boy wasn´t going anywhere except to the nearest filthy hospital down the street a few blocks. Believe me, folks, when you are at death´s door, a free flight anywhere is not on your list; much less a flight to Houston or L.A. forfree Medicare while you are lying on that plane in a comatose state so who the hell are you guys kidding? I guess I could have opted for a free flight to the states where they would bury my corpse for free. But, I opted for the incompetent surgeon in the incredibly filthy hospital in backward San Cistóbal and I am still here bugging my wife four years later.

Here is my lesson: 
If you are going to live in Mexico or Colombia, Kenya, Uganda or Upper Volta - plan to live and die there rather than fly back to Chicago to expire . Worms do not give a damn about your nationality and you will be a feast for them one way or the other. 

By the way, once the insurance company found out I had actually opted to live in Chiapas rather than simply vacation there, they withdrew the free emergency flight thing telling me that thay had thought that I was on vacation and if I were dumb enough to live there voluntarily, that was my problem.


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## RVGRINGO

That is very good advice. All of my visits to Guadalajara hospitals and eye clinics have been emergencies, with absolutely no opportunity to consider alternatives.
I accept my condition and try to keep a reasonable attitude and to avoid, or correct the typos. Admittedly, the shortage of oxygen to the brain is to blame and I may even revert to curmudgeon status on occasion. As a Canadian friend said, Nothing to lose, Eh?


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## Hound Dog

Thank you for your kind words, RV and, once again, the best to you. I hope our advice to those thinking international flights to places such as the United States at a time of medical emergency followed by the drudgery of finding sympathetic physicians and peripheral health care facilities are a rational alternative, give some food for thought. 

When I was deathly ill in Chiapas, the best advice I got was, that it was not the quality of the hospital that mattered but whether or not I had a physician who gave a damn so why ride down the mountain to Tuxtla . The particular physician I ended up with was the only one in town over the Christmas holidays as the rest were at the beach; was a biker who loved to ride up and down the steep mountain road between Tuxtla and San Cristóbal at 100 KPH on his moto and saved my life because he knew a gall bladder from a pancreas. Thank you Jesus. If I had flown back to Houston or some other U.S. place with Medicare available to me, I wold be like Charlton Heston and they would be removing my Medicare aplication card from, as Heston said, "...my cold, dead hands." so they coiuld bury me six feet under with the proper documentation to excuse my demise and their incompetence.


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## Hound Dog

There are more sides to this health care story than readily discernable. In the early 1970s. my father, 60 at the time, drove up to Birmingham some three hours distant for what was then complicated cataract surgery performed by one of the most famed eye surgeons in the world at the equally famed University of Alabama Medical Center - Birmingham and that eye surgeon botched the job and, while staying at this reknown hospital, he contracted what we think was "Legionaires Disease" at that highly prestigeous hospital and, when he got home exhausted ,he died within a day from respiratory failure whiich local doctors in our home town diagnosed as pneumonia.

Lesson: If you go to a famous hospital and are attended by famous staff, try not to die bcause that will piss them of to no end. Also, while in that hospital, try not to breathe in germs moe than absolutely necessary.


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## RVGRINGO

OK, I will add a bit more. My previous existence included some ten years of visiting the innards of hospitals on several continents, sometimes spending time in procedure rooms when new products and procedures were being evaluated, and other times with young MDs in off hour lounges, where occasional opportunistic surgeries were planned at the drop of a hat, when an OR became available; mostly gall bladder removals on hypocondriacs willing to consent. I also knew a psychiatrist who solved many of his obese lady patients chronic pain complaints with novocain. Saw them every two weeks, just like clockwork. I do not see that sort of thing in Mexico and I can vouch for the fact that the private hospitals, at least in Guadalajara, are well run and cleaner than I ever saw in the USA. Infection control here seems much more effective. Even so, I must quit visiting them!


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## Hound Dog

_


RVGRINGO said:



OK, I will add a bit more. My previous existence included some ten years of visiting the innards of hospitals on several continents, sometimes spending time in procedure rooms when new products and procedures were being evaluated, and other times with young MDs in off hour lounges, where occasional opportunistic surgeries were planned at the drop of a hat, when an OR became available; mostly gall bladder removals on hypocondriacs willing to consent. I also knew a psychiatrist who solved many of his obese lady patients chronic pain complaints with novocain. Saw them every two weeks, just like clockwork. I do not see that sort of thing in Mexico and I can vouch for the fact that the private hospitals, at least in Guadalajara, are well run and cleaner than I ever saw in the USA. Infection control here seems much more effective. Even so, I must quit visiting them! 

Click to expand...

_Quite illustrative of what I was trying to say, RV, and I personally thank you for that educational post. Your comment freaked me out a little bit but my experiences living in the famous Napa Valley filled with filthy rich Silicon Valley billionaires and in San Francisco where one would, if inexperienced, expect some of the most professional medical care on the planet, replicated your own. Of course, my experience was more facile than yours and your comment scared me even more than I was frightened by my personal esperiences in the front offices of hospitals here and there.

We sometimes don´t personally observe the fundamentals and try to beleive that our human companions in trades requring an extra special care at cleanliness and proper medicinal care are more meticulous in attending their duties than are we but as the last line in _SOME LIKE IT HOT _expressed in spades, nobody´s perfect.

By the way, my spouse and best friend for decades used be in the wine trade selling the finest wines to the top restaurant clientele and, in that capacity, she visited many kitchens of the finest restaurants in the world and she advises that, if you like to eat in the finest restaurants on earth , stay out of the kitchens.


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## Longford




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## Hound Dog

Longford´s subtle approach to universal topics including what Longford perceives as topical diversion, is always an inspiration but, as that southern senator and attorney, I believe named Sam Irvin,t as thick intellectually as Hound Dog used to say; "Ah´m just a country lawyer and Ah don´t get it." I do get it, however, and will try to stay on track in the future assuming I was off track here in my response to RV ******.

My apologies, Longford.


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## libove

*Foreign Earned Income exclusion "eligibility"? Physical presence/bona fide residence*

The IRS.GOV FAQ on the Individual Shared Responsibility Provision, item 12, makes reference to people who are "eligible" for the Foreign Earned Income exclusion. It doesn't clearly say whether they have to take the exclusion in order for this eligibility to exempt them from the individual mandate.
*It also doesn't talk about the case of people who have revoked the FEI exclusion, which - in terms of using the exclusion for the following five years of tax return filings, makes then ineligible for the exclusion.*

My guess is that the reference to "eligibility" for the FEI exclusion is meant to be taken simply, without reference to the complexity of people who, fully compliant with IRS regulations, revoke the exclusion for several years ... but "my guess" is worthless; clarity from the IRS (as the enforcer) and from the Congress (as the implementer) of the individual mandate rules is required.

Has anyone got a clear and unequivocal official statement, or failing that a clear chain of logic depending from official statements, to show that US citizens who simply are resident outside of the USA for 330+ days a year (people who would meet the bona fide or physical presence tests), *without reference to the Foreign Earned Income exclusion itself*, are exempt from the individual mandate in the ACA?

thanks,


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## libove

*Federal Register 2013-08-30 page 53651*

Hm. Responding to myself:

The Federal Register final rule on the ACA, at this link:
http://www.gpo.gov/fdsys/pkg/FR-2013-08-30/pdf/2013-21157.pdf
on page 53651, has this text:



> D. Foreign Issuer Coverage
> 1. In General
> Under section 5000A(f)(4) and § 1.5000A–1(b)(2) of the final regulations, an individual is treated as having minimum essential coverage for a month if the individual is a bona fide resident of a United States possession for the month, or if the month occurs during any period described in section 911(d)(1)(A) or section 911(d)(1)(B) that is applicable to the individual. Section 911(d)(1)(A) is applicable to a citizen of the United States who has a tax home outside the United States and is a bona fide resident of a foreign country or countries during an uninterrupted period that includes an entire taxable year. Section 911(d)(1)(B) is applicable to a U.S. citizen or U.S. resident (as defined in section 7701(b)) who has a tax home outside the United States and is present in a foreign country or
> countries for at least 330 full days during a period of 12 consecutive months.


Here we see only a reference to bona fide or physical presence tests. Nothing about the Foreign Earned Income exclusion with all of its complexities about election or revocation.

Hopefully when the TY2014 forms come out, this will be well reflected.




libove said:


> The IRS.GOV FAQ on the Individual Shared Responsibility Provision, item 12, makes reference to people who are "eligible" for the Foreign Earned Income exclusion. It doesn't clearly say whether they have to take the exclusion in order for this eligibility to exempt them from the individual mandate.
> *It also doesn't talk about the case of people who have revoked the FEI exclusion, which - in terms of using the exclusion for the following five years of tax return filings, makes then ineligible for the exclusion.*
> 
> My guess is that the reference to "eligibility" for the FEI exclusion is meant to be taken simply, without reference to the complexity of people who, fully compliant with IRS regulations, revoke the exclusion for several years ... but "my guess" is worthless; clarity from the IRS (as the enforcer) and from the Congress (as the implementer) of the individual mandate rules is required.
> 
> Has anyone got a clear and unequivocal official statement, or failing that a clear chain of logic depending from official statements, to show that US citizens who simply are resident outside of the USA for 330+ days a year (people who would meet the bona fide or physical presence tests), *without reference to the Foreign Earned Income exclusion itself*, are exempt from the individual mandate in the ACA?
> 
> thanks,


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## thesetat

FHBOY said:


> If we can leave behind all the politics of this, there is a good question to be asked:
> 
> How does the ACA affect those USA citizens living abroad as expats who are not yet old enough for Medicare (yes, some of us are that young). We are, after all, USA citizens.
> 
> I would appreciate links and citations, rather than opinions.
> 
> I left the USA as a Maryland resident and now wonder if we would be required to sign up for USA based health insurance through an exchange or face the tax penalty under the law.


I can tell you for sure that you will have to call their hotline number to sign up for Obamacare. You may qualify for an exemption like I did. If you did not file taxes for several years you are exempt or if you can show you reside outside of the USA for more than 330 days for year. But you will still have to enroll and file for the exemption. Best you go to their link and get the 800# to call for your state office where you have residency...


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## RVGRINGO

Remember, the 800 number will not work from Mexico, without a charge.


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