CMS-10466 Application for Exemption for American Indians

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

CMS-10466 - Application Exemption Tribe NSCR 2014 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⚠️ Notice: This form may be outdated.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. 0938-1190

Application for Exemption for American Indians and Alaska
Natives and Other Individuals who are Eligible to Receive
Services from an Indian Health Care Provider
Use this application
to apply for
an exemption
from the shared
responsibility
payment

•

THINGS TO KNOW

Who can use this
application?

•

What you need
to apply

•

•
•

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 2 categories of exemptions. 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. If you’re a member of an Indian tribe, you can ask the Internal
Revenue Service (IRS) for this exemption 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’re not sure, you may want to ask for an exemption.
Use this application if you and/or anyone in your tax
household is:
• A member of an Indian tribe.
• Another individual who’s eligible for health services through
the Indian Health Service, tribes and tribal organizations,
or urban Indian organizations.
If you get this exemption, you can keep it for future years without
submitting another application if your membership or eligibility for
services from an Indian health care provider remains unchanged.
You can use one application to apply for this exemption for more
than one person in your tax household.
Documents showing tribal membership or eligibility for services from
the Indian Health Service, a tribal health care provider, or an urban
Indian health care provider (see page 4).
Social Security numbers (SSNs), if you have them.
Information about people in your tax household.

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?

Send your complete, signed application with documents to the address
on page 3. 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 Help Center at 1-800-318-2596. TTY users
should call 1-855-889-4325.

Get help with this
application

•
•
•
•

Online: HealthCare.gov.
Phone: Call our 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.

MEMBER OF TRIBE/IHCP

Page 1 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 you get this exemption, we’ll give you 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 2 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

MEMBER OF TRIBE/IHCP

Page 2 of 4

STEP 2

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. Date of birth (mm/dd/yyyy)

3. Sex

/
-

4. 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 is applied correctly on your taxes. If someone wants help
getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.
5. Tell us about the federal income tax return that you plan to file.
a. Will you file jointly with a spouse?

Yes

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?
6. Do you need this exemption?
YES.

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

7. Are you a member of an Indian tribe?
YES. If yes, then leave the rest of this page blank.

NO.

8. Are you eligible to get services through an Indian health care provider only because you’re pregnant with the child of a member of an
Indian tribe?
YES. If yes, when is your baby (or babies) due (mm/yyyy)?

then leave the rest of this page blank.

NO. If no, skip to the next question.
9. Are you eligible to get services through an Indian health care provider?
YES. If yes, answer questions 10 and 11.
NO. If no, then leave the rest of this page blank.
10. If you haven’t been eligible for services through an Indian health care provider (i.e., spouse of a member of an American Indian or Alaska
Native who is eligible for services through the Indian Health Service who wouldn’t otherwise be eligible), when did you become eligible for
such services (mm/dd/yyyy)?

11. If you know that your eligibilty for services through an Indian health care provider has ended or will end (i.e., due to a divorce or will turn
19 years old and wouldn’t otherwise be eligible for such services), please provide the date (mm/dd/yyyy).

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

MEMBER OF TRIBE/IHCP

Page 3 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. I can call 1-800-318-2596 to report any changes. I understand that a change in my information could affect the
eligibility for 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 exemption 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 exemption 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

Mail completed application and documents.

Include your documentation showing tribal membership or eligibility for services through the Indian Health Services, a tribal
health care provider, or an urban Indian health care provider (see page 4), and mail your signed application 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 0938-1190. 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

MEMBER OF TRIBE/IHCP

Page 4 of 4

STEP 5

Documents to support your application.

In order to approve an exemption, we need documentation of membership in an Indian tribe or eligibility for services through
an Indian health care provider for each person who is asking for an exemption on this application.
Please submit copies of documents (not originals) based on your status or eligibility type as described below.

Member of an Indian tribe or shareholder in an Alaska Native corporation.
Submit ONE of the following:
•

Enrollment or membership document from a federally-recognized tribe or the Bureau of Indian Affairs (BIA). It must be on
tribal letterhead or an enrollment/membership card that contains the tribal seal and/or an official signature, or a Certificate
of Degree of Indian Blood (CDIB) issued by the BIA or a tribe, if the CDIB includes tribal enrollment information.

•

Document issued by an Alaska Native village/tribe, or an Alaska Native Corporation Settlement Act (ANCSA) regional or
village corporation acknowledging descent, or affiliation, or shareholder status, or participation in village or Alaska Native
community affairs. The document can also include a CDIB issued by the BIA or tribe, if the CDIB includes ANSCA shareholder
status or information regarding membership in an Alaska Native village.

Other individual who is eligible for services through an Indian health care provider.
Submit ONE of the following:
•

If you are a California Indian, a document from the Bureau of Indian Affairs (BIA) or an Indian tribe, showing a person who is
listed on the plans for distribution of the assets of Rancherias and reservations located within the state of California under
the Act of August 18, 1958, and any descendant of such an Indian; or document showing trust interests in public domain,
national forest, or reservation allotments in California; or document showing a person is a descendant of an Indian who was
residing in California on June 1, 1852, if such descendant is a member of the Indian community served by a local program of
the Indian Health Service; and is regarded as an Indian by the community in which such descendant lives.

•

Letter on facility letterhead with official signature from the Indian Health Service, tribal or urban Indian health care provider verifying
eligibility for services.

•

Tribal document acknowledging membership, descent, participation in tribal community affairs, residence on tax exempt land,
or that it regards the person as Indian. The document must be on tribal letterhead, and have a tribal seal or official signature.

•

United States Bureau of Indian Affairs (BIA) Form 4432 signed by BIA or tribal official.

•

Certificate of Degree of Indian Blood (CDIB), signed by BIA or tribal official.

Or, submit the following:
•

Birth certificate AND a document from the list above for your parent or grandparent. If the document is from your
grandparent, you must also provide a birth certificate linking your parent to your grandparent.

•

Birth certificate or adoption papers AND a document from the list above for your eligible Indian parent or guardian.

•

Marriage certificate, if non-Indian spouses are made eligible for services through an Indian health care provider, as a class,
by an appropriate resolution of the governing body of the Indian tribe or tribal organization, AND a document from the list
above for your eligible Indian spouse.

•

If you are eligible for services through an Indian health care provider only because you are pregnant with the child of a
member of an Indian tribe or a shareholder of an Alaska Native corporation, a document from the list above for the member
or shareholder.

•

If you are an urban Indian, a document showing residency in an urban Indian center, such as a rent statement, mortgage,
utility bill, or voter registration card, AND an enrollment or membership card/ID or document establishing that the individual:
–

Is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated
since 1940 and those recognized now or in the future by the state in which they reside, or who is a descendant, in the
first or second degree, of any such member;

–

Is an Eskimo or Aleut or other Alaska Native;

–

Is considered by the Secretary of the Interior to be an Indian for any purpose; or,

–

Has been determined to be an Indian under regulations promulgated by the Secretary.

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

MEMBER OF TRIBE/IHCP

APPENDIX A

Form Approved
OMB No. 0938-1191

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

MEMBER OF TRIBE/IHCP

File Type	application/pdf
File Title	Application for Exemption - tribes
Subject	Application for Exemption - tribes
Author	CMS
File Modified	2014-02-26
File Created	2014-02-25