While much attention has been placed on health care fraud perpetrated by professionals and hospitals such as overcharging Medicaid, individual patients may also abuse health coverage. Health insurance abuse is not a new problem in the U.S. Patients may receive coverage for claims with insufficient documentation, fake ailments, medication used for non-medical purposes or for ineligible patients (Morris, 2009). Estimates suggest that the amount of money paid for fraudulent claims exceed 20 percent of yearly health care expenditures yet many believe this to be a gross underestimate. (Berwick & Hackbarth, 2012). Fraud and abuse of health coverage have continued under the Affordable Care Act, despite the Federal Standardization of Health Coverage, it may seem less likely the individuals would be able to. Yet the responsibility of the individual patient will be re-emphasized at tax time. This is because of the need for individuals to reconcile their yearly income with any premium credit received.
Although when applying for a health plan under the Affordable Health Care Act it is not necessary to provide documentation as to yearly income, it is required when filing taxes. This means that individuals must take responsibility for the accuracy of what they report in applying for a premium tax credit. According to the Healthcare.gov blog (Healthcare.gpv,2016), individual’s are responsible for keeping their1095-A form, checking it to make sure it is accurate, report inaccuracies and obtain a new corrected form if necessary, and reconcile their actual yearly income with the projected income reported to obtain premium credit to lower health coverage cost. This is now part of an annual tax return and must be filed even if the individual is not required to file taxes. This means that the role of the individual health coverage recipient is one of accountability and the level of responsibility is at such a level that the individual will be fined if they fail to file the form, if they did not obtain at least the minimum amount of coverage or if they are discovered to have submitted fraudulent documentation of inadequate documentation.

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  • Berwick, D. M., & Hackbarth, A. D. (2012). Eliminating waste in US health care. JAMA, 307(14), 1513-1516.
  • Healthcare.gov, (2016, March 10). What to do if Your Form 1095-A is Incorrect [Web log post].
    Retrieved from https://www.healthcare.gov/blog/using-tax-form-1095-a/.
  • Morris, L. (2009). Combating fraud in health care: an essential component of any cost
    containment strategy. Health Affairs, 28(5), 1351-1356