Federal healthcare law and insurance coverage

When it passed into law in 2010, the central provision of the federal Affordable Care Act (ACA) was the individual mandate, which required virtually all Americans to have a medical health insurance plan that meets federal requirements or pay a tax penalty. Notably, the tax penalty associated with not having the mandated insurance was removed, effective January 1, 2019.

This means that although the ACA’s requirement to have the insurance remains in place, there is no longer a federal tax penalty for not having medical insurance. Some states have their own insurance mandates and associated penalties, however.

The U.S. Department of Health and Human Services does not currently process religious conscience exemptions to the federal individual mandate, but some Christian Scientists may be interested to know about the ACA’s hardship exemption. The granting of this exemption makes the recipient eligible to access “catastrophic” care plans on the www.healthcare.gov Health Insurance Marketplaces. See below for more information about the status of the ACA’s religious conscience and hardship exemptions, as well as other relevant information about the federal law.

Do plans offered on the state Health Insurance Marketplaces cover Christian Science care?
Not that we are aware of, no. 

What is the status of the ACA’s religious conscience exemption?
The ACA’s religious conscience exemption does extend to individuals who “rely solely on a religious method of healing,” as do many Christian Scientists. However, HHS is no longer accepting applications for this exemption, deeming it unnecessary because there is no longer a financial penalty for not having federal health insurance.

That said, the existence in law of a religious conscience exemption that Christian Scientists can qualify for is important as a legal exception to the requirement to have qualifying medical health insurance. The ACA’s religious conscience exemption therefore offers a helpful precedent. Some states have their own health insurance mandates, and we are grateful that the federal law’s religious exemption has been an influential model for several of them. 

If you have questions about whether your state has an individual mandate and/or a relevant religious conscience exemption, visit healthcare.gov or feel welcome to contact your state Committee on Publication.

How might the ACA’s hardship exemption be relevant to those who use Christian Science care services?
The ACA’s hardship exemption became available in 2018 to those who can’t find insurance coverage on their state’s health insurance Marketplace for the type of health care services they want; this includes desired coverage of services from a Christian Science practitioner, a Christian Science nurse, and a Christian Science nursing facility. This 'specialty care' hardship exemption continues to be available for the current year and beyond, and also retroactively for up to two prior calendar years.

As mentioned above, having a hardship exemption is one of the ways an individual can qualify to purchase catastrophic health insurance on the ACA health insurance marketplace. This may afford additional tax benefits to those coupling a qualifying catastrophic plan with a Health Savings Account (HSA), which can be used to pay for healthcare products and services, including Christian Science care.

Applications for this exemption are submitted separately from any tax filings by using the federal government’s ACA hardship exemption form (located here) and designating #14 as the hardship being claimed, and then briefly explaining the nature of the hardship. Note, this is not a religious conscience exemption. It is a hardship exemption, with the designated hardship being that one’s desired health care is not covered by any of the plans available via the respective state’s insurance exchange.

Do Medicare and Medicaid meet the ACA’s individual insurance requirement?
Yes. If you have Medicare Part A or Medicaid, you already meet the law’s requirement to have qualifying health insurance coverage.

What if I am eligible for Medicare but have not signed up or am not sure whether I'm enrolled?
To learn what your options are, visit Medicare's website or your local Social Security office.

Resources for General Medicare Questions

• Social Security Administration: The Social Security Administration website provides a good general overview of the Medicare program with an emphasis on eligibility and enrollment procedures.

• Medicare.gov: This federal government website provides detailed information on Medicare benefits (including the various parts of Medicare), coverage options, and when and how to enroll.

• State Health Insurance Benefits Counseling: Every State provides free counseling about Medicare and other types of government benefits to individuals who are Medicare eligible. This link leads to a list of contact information for the benefits counseling program in each State.

• Christian Science nursing facility coverage under Medicare: Christian Science nursing facilities can also be a good source of information about Medicare. This link provides contact information for the Christian Science nursing facilities that participate in Medicare.

Some questions to consider when navigating Medicare enrollment

Do I need to enroll in any or all of the parts of Medicare?
The Medicare program has four parts:

• Part A: Institutional and inpatient health care, such as hospital, skilled nursing facility and religious nonmedical health care institution (RNHCI) care. (Christian Science nursing facilities that participate in Medicare are categorized as RNHCIs under federal law.)

• Part B: Outpatient health care, such as x-ray, emergency room visits, laboratory tests, ambulance services, durable medical equipment, and preventive vaccines. (Parts A and B are often collectively referred to as “Original Medicare”.)

• Part C (Medicare Advantage): Private managed care health insurance plans that replace coverage under Medicare Parts A and B.

• Part D: Private prescription drug plans.

There is no legal requirement to sign up for (enroll in) any or all of the parts of Medicare. As explained below, however, people who do not enroll when they first become eligible* but decide to do so later, may be subject to late enrollment penalties. 

Most people who are receiving Social Security payments when they reach Medicare age will be automatically enrolled in Parts A and B of Medicare and receive a Medicare card in the mail. To learn more about Medicare entitlement and enrollment, as well as what to do if you were automatically enrolled but wish to decline, please contact https://www.ssa.gov/medicare. 

*Under federal law, Medicare is the secondary payer for individuals over 65 who are still covered by an employer group health plan because they or a spouse are currently working. These individuals usually have the option of waiting to enroll in Medicare until their employer-provided coverage ends. Individuals in this situation should check with their employer and the Social Security Administration concerning these rules.

Do I want to enroll in Original Medicare (Parts A and B) or a Medicare Advantage plan (Part C)?
Original Medicare and Medicare Advantage are alternatives — you can’t enroll in both at the same time. Under Original Medicare, health care providers are paid directly by the government. Medicare Advantage plans are private insurance plans that provide the same benefits as Original Medicare. They may also offer additional benefits (e.g., vision, dental, gym memberships), and often cost less than Original Medicare. Medicare Advantage plans are required to cover RNHCI (religious nonmedical health care institutions, including participating Christian Science nursing facilities) care under federal law. However, actually obtaining payment for this service has historically been much more difficult under Medicare Advantage than under Original Medicare.

If I’m considering a Medicare Advantage plan, does the plan I’m interested in refer to coverage of religious nonmedical health care institution (RNHCI) services?
It is important to review the terms and benefits of any health insurance plan you are considering. If coverage of RNHCI (participating Christian Science nursing facilities) services is a motivating factor in your selection of Medicare coverage, it can be particularly helpful to determine whether a Medicare Advantage plan specifically refers to RNHCI coverage in the plan documents. This is because Medicare Advantage plans follow managed care procedures that involve additional rules that do not apply under Original Medicare. For example, you may be required to use “‘in-network” providers or to obtain prior authorization from the plan before inpatient admission and re-approval for a continued stay. 

Even if Medicare Advantage plan documents refer to coverage of RNHCI services, whether a particular stay is covered will depend on the individual situation. However, it can be helpful to know about managed care requirements in advance and to be able to point to RNHCI coverage language if you disagree with a plan’s decision that a particular stay at a Medicare-participating Christian Science nursing facility is non-covered. 

Do I want to enroll in Medicare Part B?
Medicare Part B covers outpatient health care services such as emergency room visits, ambulance services, X-rays, physician care, laboratory testing, durable medical equipment, and preventive vaccines. A few important considerations with regard to Part B include:

• If you do not enroll in Part B when you are initially eligible for Medicare but enroll later, you will be required to pay a late enrollment penalty. 

• Some forms of insurance coverage (e.g., TRICARE, some employer retiree plans, Medigap policies, Medicare Advantage plans) may require you to be enrolled in Part B.  

• Some providers have contractual relationships that require them to bill Medicare for covered services provided to someone who is eligible but not enrolled. In this circumstance, Medicare will usually pay for the services, but the individual will be automatically enrolled in Part B and required to pay the late enrollment penalty.

If I’m considering a Medicare Advantage plan, does the plan include prescription drug (Part D) coverage?
Like Medicare Part B, Medicare Part D has a late enrollment penalty if you don’t enroll during your initial eligibility period but decide to enroll later. Some Medicare Advantage plans include prescription drug coverage but others do not. If you do not enroll in a Medicare Part D drug plan when you first become eligible for Medicare but later decide to enroll in a Medicare Advantage plan that includes drug coverage, you will be assessed a Part D late enrollment penalty.

Do I want a Medigap plan?
Medigap plans are available to people enrolled in Original Medicare (but not Medicare Advantage). They pay for out-of-pocket costs related to services that are covered by Medicare (e.g., coinsurance, deductibles). The benefits available in Medigap plans are standardized, but the cost and availability of plans vary widely. These plans cost less if purchased at initial enrollment due to certain federal rules; if you are initially enrolled in Original Medicare and later choose to switch to a Medicare Advantage plan, you will be required to drop any Medigap coverage you have. If you later decide to return to Original Medicare and want a Medigap plan again, you will likely end up paying a higher premium for the new Medigap plan. 

Do Medicare and Medicaid meet the ACA’s individual insurance requirement?
Yes. If you have Medicare Part A or Medicaid, you already meet the law’s requirement to have qualifying health insurance coverage.

What are HSAs?
Health savings accounts (HSAs) are custodial accounts that can be set up through financial institutions such as banks and credit unions, either directly by an individual or through an employer-sponsored plan. HSAs provide tax benefits to an individual for setting aside money to pay for current and future health care expenses. Tax laws only allow establishment of and contribution to an HSA when the account holder has health coverage through an HSA-compatible health plan (also sometimes referred to as a “high-deductible,” “self-directed,” or “catastrophic” health insurance plan).* Those kinds of plans usually have lower monthly premiums than other health plans do—because the annual deductibles are higher. The motivation behind the HSA-compatible plan is to encourage saving (or investing) of money that would otherwise be spent on health insurance premiums, to give the account holder more discretion in how those dollars are used to pay for immediate or future out-of pocket health care needs.

Who can set up an HSA?
Generally speaking, if you are covered by an HSA-compatible health plan, you can set up an HSA. Except for some limited exceptions, such as dental, vision, accident, disability, and long-term care plans, you are not eligible to establish an HSA if you have other health coverage through a non-HSA-compatible health plan, including Medicare. 

Contributions to an HSA
Contributions to the HSA can only be made when the account holder has health coverage through an HSA-compatible health plan. The IRS sets annual contribution limits, and contributions can come from a variety of sources, including account holders, employers, family members, and even from a limited one-time roll-over of IRA funds. These contributions are not taxed, nor are distributions (provided they are used for qualifying health care expenses). If HSA funds are used for non-qualifying expenses before age 65, the account holder not only is obligated to pay regular income tax on the distribution, but is also subject to a penalty for early withdrawal. Once the account holder turns 65, non-qualifying distributions are subject only to regular income tax, without penalty.

HSAs and Christian Science care
The determination of what health/medical expenses can be legally paid for by an HSA is governed by Section 213(d) of the Internal Revenue Code, which defines “medical expense” for purposes of income tax deduction to include amounts paid “for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body.”

Accordingly, over the years, payments made by individuals to Christian Science practitioners, Christian Science nurses, and Christian Science nursing facilities that relate to the healing of physical or mental conditions generally have been treated as tax-deductible under Section 213(d) of the Internal Revenue Code. This is consistent with IRS regulations interpreting this section, which approve expenses for “treatments affecting any portion of the body” and for the “prevention or alleviation of a physical or mental defect or illness”, including “hospital” and “nursing services” and “other diagnostic and healing services”.  While this would not likely extend to expenses unrelated to a health condition, there appears to be flexibility for coverage of expenses that directly relate to healing of a physical or mental condition.

However, you should not construe this as individual legal advice. Your eligibility to establish and contribute to an HSA, as well as the eligibility of specific health/medical expenses, should be discussed with an attorney, tax advisor, or benefits consultant who is qualified to advise you under your particular tax circumstances.

*Please note that some high-deductible coverage is compatible for use in conjunction with a health savings account (HSA), and some is not. If you are interested in pairing a high-deductible health plan with an HSA, you will want to verify that the coverage is an HSA-compatible health plan. It should reference "HSA" somewhere in the plan name or description, but you should also verify that in writing with the insurance carrier.

Federal Employee Health Benefits Plan (FEHBP) Program
For the past 60+ years, health plans under the Federal Employee Health Benefits Plan (FEHBP) Program have provided some form of coverage of Christian Science care services. Because the services covered and extent of the coverage varies among the plans, you should review the plan materials carefully and direct any questions to the specific health plan. 

• Compass Rose Health Plan: Access the 2026 Plan Brochure (accessible to all Federal employees as of 2025)

TRICARE Select
For the past 60+ years, TRICARE Select, the insurance program that covers families and dependents of military service members, has covered Christian Science care services. For more information, feel welcome to contact the U.S. Federal Office directly at federal@csps.com.

The services covered and the extent of coverage of Christian Science care services provided in the health plans below may vary, so it is important to review the plan materials carefully and direct any specific coverage questions to the plan involved. Your Human Resources department may also be helpful if the coverage is employer-based.

• Alaska state employee plan

• CalPERS Choice Basic plan

• Illinois state employee plan

• Illinois state retiree, annuitant, and survivor plan

• Los Angeles City retired employee plan

• Missouri state employee plan

• Nevada state employee plan

• Oklahoma state employee plan

• Oregon state employee plan

• Self-insured schools of California plan

• South Dakota state employee plan

• West Virginia public employee plan