Form CMS-10466 Application Exemption - Hardships

Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions

Application_Exemption_Hardship-12192013-508

Exemption Applications - Eligibility for Exemptions

OMB: 0938-1190

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1190 can be found here:

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Form Approved
OMB No. 0938-XXXX

THINGS TO KNOW

Application for Exemption from the Shared Responsibility
Payment for Individuals who Experience Hardships
Use this application
to apply for
an exemption
from the shared
responsibility
payment

•

Starting in 2014, every person needs to have health coverage or
make a payment on their federal income tax return called the
“shared responsibility payment.”

•

Some people are exempt from making this payment. This application
includes one category of exemption. There are other applications
for other categories of exemptions. You may apply for certain other
categories of exemptions when you file your federal income tax return.

•

You don’t need to ask for an exemption if you’re not going to file a federal
income tax return because your income is below the filing threshold. If
you aren’t sure, you may want to ask for an exemption.

Who can use this
application?

•

Use this application if you and/or anyone in your tax household
have experienced a hardship that keeps you from getting health
coverage. See page 1 for the list of hardships.

•

If you get a hardship exemption, you may qualify for catastrophic
coverage.

•

You can use one application to ask for this exemption for more than one
person in your tax household.

•

Documents that support your claim of hardship (see page 1.) If you can’t
obtain the documents, call the Health Insurance Marketplace Call Center
at 1-800-318-2596. TTY users should call 1-855-889-4325.

•

Social Security numbers (SSNs), if you have them.

•

Information about people in your tax household.

What you need to
apply

Why do we ask for
this information?

We ask for Social Security numbers and other information to make
sure your exemption is counted when you file your federal income tax
return. We’ll keep all the information you give private and secure,
as required by law. To view the Privacy Act Statement, go to
HealthCare.gov or see instructions.

What happens
next?

Except for cancellations, send your complete, signed application to the
address on page 4. We’ll follow-up with you within 1–2 weeks and let you
know if we need additional information. If you get this exemption, we’ll give
you an Exemption Certificate Number that you’ll put on your federal income
tax return. If you don’t hear from us, visit HealthCare.gov, or call the Health
Insurance Marketplace Call Center at 1-800-318-2596. See page 4 for next
steps for cancellations.

Get help with this
application

•

Online: HealthCare.gov.

•

Phone: Call the Health Insurance Marketplace Call Center at
1-800-318-2596.

•

In person: There may be counselors in your area who can help.
Visit HealthCare.gov or call 1-800-318-2596 for more information.

•

En Español: Llame a nuestro centro de ayuda gratis al
1-800-318-2596.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

Español, llame 1-800-318-2596. If you need help in a language other than English, call 1-800-318-2596 and tell the customer service representative
the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.

HARDSHIP

Page 1 of 4

Hardship Categories and Documentation
You may qualify for a hardship exemption if you experienced one of the following:

Hardship number

Category

Submit this documentation
with your application

You were homeless.

None

You were evicted in the past 6 months or were
facing eviction or foreclosure.

Copy of eviction or foreclosure notice

You received a shut-off notice from a utility
company.

Copy of shut-off notice from a utility company

You recently experienced domestic violence.

None

You recently experienced the death of a close
family member.

Copy of death certificate, copy of death notice
from newspaper, or copy of other official notice
of death

You experienced a fire, flood, or other natural
human-caused disaster that caused substantial
damage to your property.

Copy of police or fire report, insurance claim,
or other document from government agency,
private entity, or news source documenting event

You filed for bankruptcy in the last 6 months.

Copy of bankruptcy filing

You had medical expenses you couldn’t pay in the
last 24 months.

Copies of medical bills

You experienced unexpected increases in
necessary expenses due to caring for an ill,
disabled, or aging family member.

Copies of receipts related to care

You expect to claim a child as a tax dependent
who’s been denied coverage in Medicaid and the
Children’s Health Insurance Program (CHIP), and
another person is required by court order to give
medical support to the child.

Copy of medical support order AND copies of
eligibility notices for Medicaid and CHIP showing
that the child has been denied coverage

As a result of an eligibility appeals decision, you’re
eligible either for: 1) enrollment in a qualified
health plan (QHP) through the Marketplace,
2) lower costs on your monthly premiums, or
3) cost-sharing reductions for a time period when
you weren’t enrolled in a QHP through
the Marketplace.

Copy of notice of appeals decision

You were determined ineligible for Medicaid
because your state didn’t expand eligibility for
Medicaid under the Affordable Care Act.

Copy of notice of denial of eligibility for Medicaid

You received a notice saying that your current
health insurance plan is being cancelled,
and you consider the other plans available
unaffordable.

Copy of notice of cancellation

You experienced another hardship in obtaining
health insurance.

Please submit documentation if possible

(Put this number in
box 8 on page 3.)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

HARDSHIP

Page 2 of 4

Use blue or black ink to complete this application.

STEP 1

Tell us about yourself.

(We need one adult in the tax household to be the contact person for your application.)
1. First name

Middle name

Last name

Suffix

2. Home address (Leave blank if you don’t have one.)

4. City

3. Apartment or suite number

5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)

10. City

11. State

14. Phone number

(

9. Apartment or suite number

)

–

16. Do you want to get information about this application by email?

12. ZIP code

13. County

15. Other phone number

(

Yes

)

–

Email address:
17. What is your preferred spoken or written language (if not English)?

STEP 2

Tell us about your tax household.

Who do you need to include on this application?
Tell us about each person in the tax household who needs an exemption (don’t include dependents who aren’t asking for this
exemption for themselves.) If your request for an exemption is approved, you’ll get an Exemption Certificate Number with your
approval letter. Keep this for your records. You’ll need to put this number on your federal income tax return at the time you
file taxes.

Complete Step 2 for each person in your tax household, except for dependents who aren’t asking for this
exemption for themselves.

Start with yourself, then add all other adults (whether or not they’re requesting this exemption) and any dependents, if you
want this exemption for them. Make additional copies of page 3 and attach them for each additional person. You don’t need
to give a Social Security number (SSN) for members of your tax household who don’t need this exemption. Someone asking for
an exemption may still be eligible for one even if they don’t have an SSN. We’ll keep all the information you provide private and
secure, as required by law. We’ll use personal information only to check if you’re eligible for an exemption.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

HARDSHIP

STEP 2

Page 3 of 4

If you have more than one person to include,
make a copy of this page and complete.

Complete Step 2 for yourself and/or anyone on your same federal income tax return. Don’t fill this out for any dependents who aren’t asking for
this exemption for themselves.
1. First name

Middle name

Last name

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

4. Sex

5. Social Security number (SSN)

Suffix

Male

Female

If you’re requesting an exemption for yourself and you have an SSN, you must provide it. You aren’t required to have an SSN to
get this exemption. If you’re not requesting an exemption for yourself, providing your SSN can be helpful since it can speed up the
application process. We use SSNs to help make sure that if you get an exemption, it’s applied correctly on your taxes. We also use SSNs to
check income and other information to see who’s eligible for help with health coverage costs. For help getting an SSN, call 1-800-772-1213 or
visit socialsecurity.gov. TTY users should call 1-800-325-0778.
6. Tell us about the federal income tax return that you plan to file.
Yes

a. Will you file jointly with a spouse?

If yes, name of spouse:
b. Will you claim any dependents on your tax return who are requesting this exemption?

Yes

If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return?

Yes

If yes, please list the name of the tax filer:
How are you related to the tax filer?
7. Do you need this exemption?
YES.

NO. If no, leave the rest of this page blank.

If you have multiple hardships to include, please make a copy of this page for each hardship and answer questions 8–11.
8. Use page 1 to write the number of the hardship you experienced in this box:
9. Unless you’re applying for hardship #12 (Medicaid ineligibility) or #13 (cancellation), please explain how this hardship kept you from getting
health coverage for the time period for which you’re requesting an exemption:

10. When did this hardship start? (mm/dd/yyyy)

11. When did this hardship end? (mm/dd/yyyy). If you’re still experiencing this hardship, check this box:

You must include any documents described on page 1 for the exemption you’re requesting. If you can’t get the documents, call the
Marketplace Call Center at 1-800-318-2596.
12. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

13. Race (OPTIONAL—check all that apply.)
White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
Korean

Vietnamese
Other Asian
Native Hawaiian

Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

HARDSHIP

Page 4 of 4

STEP 3

Read & sign this application.

•

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this
form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false and/or untrue
information.

•

I know that I must tell the Health insurance Marketplace if anything changes (and is different than) what I wrote on this
application within 30 days of that change. I can call 1-800-318-2596 to report any changes. I understand that a change in my
information could affect the eligibility for an exemption for myself or member(s) of my household.

•

I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual
orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file.

What should I do if I think the results of my application are wrong?
If you don’t agree with the results of your application, you can ask for an appeal. Here’s important information to consider when
requesting an appeal:
•

The Health Insurance Marketplace must receive your appeal request within 90 days of the date of the notice of the
application results.

•

You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or
other individual. Or, you can request and participate in your appeal on your own.

•

The outcome of an appeal could change the eligibility of other members of your household.

To appeal the results of your application, call 1-800-318-2596. TTY users should call 1-855-889-4325. You can also mail an
appeal request form or your own letter requesting an appeal to Health Insurance Marketplace – Exemption Processing,
465 Industrial Blvd., London, KY 40741.
Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized representative you
may sign here, as long as you’ve provided the required information listed in Appendix A.
Signature

Date (mm/dd/yyyy)

STEP 4
CANCELLATIONS ONLY: Provide this form & documents to a health plan.
In order to get catastrophic coverage, provide this form and a copy of the notice of cancellation you received to the health
insurance company that offers the catastrophic plan you want.
You can get information about available catastrophic plans by visiting HealthCare.gov/health-plan-information or by calling
1-800-318-2596. TTY users can call 1-855-889-4325.

ALL OTHER TYPES: Mail completed application & documents.
Mail your signed application and the documents listed on page 1 for the exemption you’re requesting to:

Health Insurance Marketplace – Exemption Processing
465 Industrial Blvd.
London, KY 40741

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-XXXX. The time required to complete this information collection is estimated to
average 16 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

HARDSHIP

APPENDIX A

Form Approved
OMB No. 0938-XXXX

Assistance with completing this application
You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters
related to this application, including getting information about your application and signing your application on your behalf.
This person is called an “authorized representative.” If you ever need to change your authorized representative, contact the
Marketplace. If you’re a legally appointed representative for someone on this application, submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)

2. Address

3. Apartment or suite number

4. City

5. State

7. Phone number

(

)

6. ZIP code

–

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all
future matters related to this application.
10. Your signature

11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-318-2596. Para obtener una copia de este formulario en

HARDSHIP

File Type	application/pdf
File Title	Application for Exemption for Individuals who Experience Hardships
Author	CMS
File Modified	2013-12-19
File Created	2013-12-19