Form CMS-10466 Application Exemptions Shared Responsibility for FFM's

Patient Protection and Affordable Care Act; Exchange Functions: Eligibility for Exemptions (CMS-10466)

CMS-10466 - Appendix C - Affordability-FFE-Exemption-Application

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⚠️ Notice: This form may be outdated.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:

2024-03-14 - Revision of a currently approved collection

Document [pdf]

Download: pdf | pdf

Application for exemption for Individuals who are Unable
to Afford Coverage and are in a State with a Federally
Facilitated Marketplace
Use this application
to apply for an
affordability
exemption

OMB Control Number 0938-1190
Expiration Date: XX/XXXX

For 2018:
• 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 the Shared Responsibility Payment. This
application is for an exemption based on health coverage being unaffordable to you. If
you qualify for the exemption, it will apply only to months in the future, not previous
months.
• You don't need to apply for an exemption if you're not planning to file a tax return. If
you're not sure if you'll file, you may want to apply for an exemption anyway.

For 2019 and future years:
• The Shared Responsibility Payment no longer applies. You don't need to apply for an
exemption unless you're planning to purchase catastrophic coverage.
• You can enroll in a "catastrophic" health plan if you qualify for an affordability exemption.
• For more information on catastrophic health plans, please see "Step 5" of this
application.

Who can use this
application?

For 2018:
• List everyone on your same federal income tax return on this application. If someone in
your household files taxes separately, they must fill out their own application.
For 2019 and future years, use this application only if you or anyone in your tax
household is unable to afford health coverage and you want to enroll in a
catastrophic plan.

When can you get
this exemption?

What you need to
apply

Why do we ask for
this information?
Get help with this
application

• Use this application to ask for an exemption for months in the future. If you want this
exemption for a whole calendar year, you need to request it before January 1 of that
year.
• You can’t use this application to get this exemption for time in the past. If you need this
exemption for months in the past, you can apply for it when you file your tax return
instead.
• Employer and income information for everyone in your tax household.
• Information about any job-related health coverage available to your family.
• Documents that show your expected yearly household income for the year you need this
exemption. See page 5 for examples of documents you can send. Income documents
must not be older than two years.
• We ask for Social Security numbers and other information to make sure your exemption
information is sent to the Internal Revenue Service (IRS) to match your tax return and to
correctly match to your coverage application. 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/privacy.
• Online: HealthCare.gov/exemptions.
• Phone: Call the Marketplace Call Center at 1-800-318-2596. (TTY: 1-855-889-4325)
• In person: There may be trained assisters in your area who can help. Visit
localhelp.healthcare.gov, or call the Marketplace Call Center.
• En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.
• Other languages: If you need help in a language other than English, call 1-800-318-2596.
We’ll provide free help in your language.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov/exemptions, or call 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. We’ll provide free help in your language. TTY: 1-855-889-4325

FFM-AFFORDABILITY 1.06

Page 1 of 7

STEP 1: Tell us about yourself
The person who files a federal income tax return in your household should be the contact person for this
application, and is known as "Person 1". If you're applying for an exemption for a child, an adult who claims
the child on his or her federal income tax return should fill out and sign this application, even if the adult
doesn't need the exemption.
Do you live in Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa,
Kansas, Kentucky, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire,
New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South
Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, or Wyoming?
YES. Fill out this application.
NO. Download the SBM-Affordability exemption application if you live in a state not listed above.
You need to submit a different application if you live in California, Colorado, the District of Columbia, Idaho,
Massachusetts, Minnesota, Nevada, New York, Rhode Island, Vermont, or Washington.
Use your legal name
1. First name

Middle name

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

Suffix

3. Apartment or suite number

4. City

5. State

8. Mailing address

Last name

6. ZIP code

7. County, parish, or township
9. Apartment or suite number

(Select if same as home address)

10. City

11. State

12. ZIP code

13. County, parish, or township

Please provide a phone number so we can contact you if necessary. We won't use your number for anything else.
14. Phone number (###-###-####)

Best time to call:
Afternoon
Morning
Evening

15. Other phone number (###-###-####)

Best time to call:
Afternoon
Morning
Evening

Weekend

16. Do you want to get correspondence from the Marketplace?.....................................................................................................................

Yes

Email address:
17a. What is your preferred spoken language?

Optional:
(Select all
that apply)

18. If Hispanic/Latino, ethnicity:
19. Race:

White

17b. What is your preferred written language?

Mexican

Black or African American

Vietnamese

Other Asian

Mexican American

Puerto Rican

American Indian or Alaskan Native

Native Hawaiian

Guamanian or Chamorro

Chicano/a

Filipino

Japanese

Samoan

Cuban

Other

Korean

Asian Indian

Other Pacific Islander

Chinese

Other

STEP 2: Tell us about your tax household and your projected income
Who to include on this application:
• The adult who files the federal income tax return for this household – list this person, who will be known as "Person 1", on the first line of the
table on the next page.
• A spouse who’s filing taxes jointly with you.
• Anybody Person 1 claims as a dependent on the federal income tax return.
You should apply for this exemption based on how you file taxes, with the following exception: If you’re 21 or older and included as a dependent
on someone else’s tax return, submit your own exemption application.

Who NOT to include on your application:
• A spouse who files taxes separately from you. Spouses who file separately must fill out a separate exemption application for themselves and
include every person they claim on their tax return.
• Anyone who lives with you but isn’t (or won’t be) listed on your tax return for the year(s) you want this exemption.
For 2017 and 2018, If you don’t plan to file taxes, you don’t need to apply for an exemption.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov/exemptions, or call 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. We’ll provide free help in your language. TTY: 1-855-889-4325

FFM-AFFORDABILITY 1.06

Page 2 of 7

STEP 2: Tell us about any health coverage and your projected income
The person in line 1 below, who will be known as "Person 1", must be the person who files a federal income
tax return for the household, even if the person doesn’t need an exemption.
For each person included on the federal income tax return, select their relationship to Person 1, the name,
date of birth, SSN, sex, and whether they want an exemption.
You must give your Social Security number (SSN) if you have one. In the table below include the SSN for
anyone requesting the exemption who has an SSN. An SSN is not necessary to qualify for the exemption. We
use SSNs to match exemptions with the right tax returns and to correctly match to your coverage
application. For help getting an SSN, visit socialsecurity.gov or call 1-800-772-1213. (TTY: 1-800-325-0778)

First name

Relationship to Person 1

Social Security

Last name

Date of birth
number
(mm/dd/yyyy) (###-##-####)

Sex

Want
exemption?

1 Self
2
3
4
5
6
7
2. For what year and months do you or members of your tax household need this exemption?
Year

Months

January

February

March

April

May

June

July

August

September

October

November December

Answer the following questions for the below person.
MI

First name
3. Are you pregnant?......................................................................

Yes

Last name
No

a. If yes, how many babies are expected during this pregnancy?
4. Are you, your spouse, or another person in your household the main caretaker of a child
under the age of 19?............................................................................................................................................................................................

Yes

5. Within the past 6 months, have you used tobacco regularly (4 or more times per week on average,
excluding religious or ceremonial uses)?..........................................................................................................................................................

Yes

6. Are you a U.S. citizen or U.S. national?
YES. If yes, skip to question 9.
NO. If no, continue to question 7.
7. Are you a naturalized or derived citizen? (This usually means you were born outside the United States)
YES. If yes, skip to question 9.
NO. If no, continue to question 8.
8. If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status?

Immigration document type

Status type (optional)

YES. Enter the document type in the space below.

Write your name as it appears on your immigration document.

FFM-AFFORDABILITY 1.06

Page 3 of 7

STEP 2: PERSON 1 Tell us about any health coverage and your projected income
Other health coverage:
9. Are you offered health coverage from a job?
Select "yes" even if the coverage is from someone else's job, such as a parent or spouse.
Also select “yes” if you are offered the coverage but have not signed up for it.
YES. If yes, you'll need to complete and include Health Coverage from a Job.
NO.

10. Are you enrolled in any of these kinds of health coverage?
COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, other..................................................................

Yes

Current job & income information
Tell us about any income you have made or expects to make from a job, self-employment, unemployment, retirement, pensions, rental properties,
fishing/farming, alimony, and Social Security (if taxable) during the year you want the exemption. You must submit a support document for each
type of income listed.
11. Do you expect any income during the year you want this exemption?
YES. If yes, answer the income questions below.
NO. If no, skip to next person or Step 4, Signature Page.

Job 1
12a. Are you self-employed?........................................................................

Yes

13a. Employer name (as listed on pay stub or W-2):

How often do you get this amount?

14a. Amount (wages, tips, commissions, bonuses, or
overtime before taxes):

$
15a. When did you start this job? (mm/dd/yyyy)

16a. When did/will this job end? (mm/dd/yyyy)

Select if this job doesn't have an end date

17a. If you don't expect to get this income every month, fill in the months that you expect to get income from this job:
Year

Months you expect to get job income

January

February

March

April

May

June

July

August

September

October

November December

Remove Job

FFM-AFFORDABILITY 1.06

Page 4 of 7

STEP 2: PERSON 1: Tell us about your projected income
Other Income: Tell us about other income you report on a federal income tax return. List the income type,
amount (before taxes) and how often you get it. Some common types of income are listed below. If you
have additional income you report on a federal tax return, include it under “Other”.
NOTE: You don’t need to tell us about income that’s not reported on a tax return, like child support,
veteran’s payment, food stamps, Social Security benefits, old age benefits that aren’t taxable, or
Supplementary Security Income (SSI) benefits.
18. Do you expect to get taxable income from a source other than a job or self-employment?
YES. If yes, fill in the table below.
NO. If no, skip to question 19.

Type of income

Amount

Number of
How often
Date ended / Fill in if no months you
(Weekly, Every 2 weeks,
Date started
expected expect to get
Twice a month, Monthly,
will end
(mm/dd/yyyy)
Quarterly, Semi-annually,
(mm/dd/yyyy) end date this income
Yearly)
per year

Unemployment
Retirement account withdrawals (taxable amounts ONLY)
Pensions
Farming/fishing (net)
Rental/royalty (net)
Alimony received
Social Security (taxable amount ONLY)
Other (indicate type)

Deductions: If you pay for certain things that can be deducted on a federal income tax return (see IRS Form 1040, lines 23-35 or IRS Form 1040A,
lines 16-19), fill in information about which deductions you plan to take.
19. Do you expect to take any deductions for the year you're requesting this exemption?
YES. If yes, fill in the table below.
NO. If no, skip to next person or Step 4, signature page.

Type of deductions

Estimated yearly

Did you take this

amount

deduction last year?

Alimony paid

Yes

IRA deduction

Yes

Student loan interest deduction

Yes

Other (select type from list)

Thanks! This is all we need to know about you.

FFM-AFFORDABILITY 1.06

Page 5 of 7

STEP 3: Proof of yearly income
You MUST submit proof for each type of income you have listed for each person on this application. We can’t approve this
exemption without proof of income. The table below lists possible documents for each type of income. You may submit other
documents, not on the list, if they’re included in the income amount you listed on your application.
If you expect your income to increase or decrease during the year for which you’re requesting this exemption, you can provide
other documents, like a document that states when contract work will end. If any of your income comes from freelance work, you
can fill out an accurate, detailed record of your expected income and expenses for the year.

Income Type

Documents

All income types

• A copy of your most recent federal income tax return, Form 1040, if your income and deductions
listed on this application are similar to your last tax return.
• One or more pay stubs that show the typical pay and hours you work at the job. The pay stubs
should show the gross amount and any tips, commissions, bonuses, or overtime pay.
• Wages and tax statement (W-2) from the most recent year.
• 1099-MISC (Non-employee compensations).

Job

Net self-employment

• Records of self-employment income and expenses.
• Schedule C.
• Form 1120S.
• Other recent tax documents showing self-employment.
• Copy of a check or other evidence of income for the services you provide.

Other Income

Documents

Unemployment

• Letter from government agency for unemployment benefits. If the document doesn't list the start
and end dates, include on the document your best estimate of when the benefits will end.

Retirement (taxable amounts ONLY)

• 1099 or relevant tax document that list any withdrawal amounts.
• Document showing taxable amount from account withdrawals.

Pension

• Pension letter.
• 1099 or relevant tax document.

Rental/royalties (net)

• Lease agreement for land or property you own with lease amount/frequency.
• Document showing royalty income.
• 1099-MISC (royalty/rental income fields).

Alimony paid/received

• Court order or legal documents showing the monthly alimony amount and the start and end dates
(if applicable).
• Schedule C, F.
• 1099-G.

Farming/fishing (net)
Social Security (taxable amounts ONLY)

• Copy of most recent Form 1040 that shows the taxable amount in line 20b. Don't send copies of
your benefit or COLA letter UNLESS the taxable amount is listed on it.

FFM-AFFORDABILITY 1.06

Page 6 of 7

STEP 4: Read, print & sign this application
You won’t be able to print and sign your application until you’ve filled out all required information. We can’t process unsigned
applications or accept digital signatures.
I agree that:
• 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 intentionally provide false or
untrue information.
• 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 hhs.gov/ocr/office/file.
1. Is anyone applying for an exemption on this application incarcerated (detained or jailed)?....................................................
If yes, tell us the person's name. The name of the incarcerated person is:

Yes

Fill in here if this person is facing
disposition of charges.

We need this information to check your eligibility for an exemption. We’ll check your answers using information in our electronic databases from
the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information
doesn’t match we may ask you to send us proof.
The person on line 1, known as "Person 1", should sign this application.
The person who signs must be an adult over the age of 18 who files the federal income tax return for the household. If you’re an Authorized
Representative, you may sign here as long as Person 1 fills out and signs the "Help with this application" form on page 7 of this application.
Print out application and have Person 1 sign.

Date signed (mm/dd/yyyy)

STEP 5: Mail completed application
Note: A page that lists the documents you need to submit will print at the end of this application.

Mail your signed application and copies (do not send originals) of the documents listed on the page that will print at the end of this application to:

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

What happens next?
We’ll call you if we need more information. If we don’t reach you by phone, we’ll send a letter. You’ll get a letter in the mail after we’ve processed your
application.
• If your application is approved, we’ll send an Exemption Certificate Number (ECN) for each approved member of your tax household to use on your
federal income tax return for the year members of your tax household didn’t have coverage. You’ll provide the ECN when you file your return for the
year your exemption has been approved.
• If you or other members of your tax household don't qualify for the exemption, the letter will explain why.
• If you don’t hear from us within 30 days, contact the Marketplace at 1-800-318-2596. (TTY: 1-855-889-4325)

What if I think the results of my exemption application are wrong?
You can appeal. Important information about an appeal:
• The Health Insurance Marketplace must receive your appeal request within 90 days of the date of the application results notice.
• You may have a relative, friend, legal counsel, or another spokesperson, including an Authorized Representative, help you appeal or participate in your
appeal. This is optional.
• The outcome of an appeal could change the eligibility of other members of your tax household.
To appeal your exemption application results, visit HealthCare.gov/marketplace-appeals. Or call the Marketplace Call Center at 1-800-318-2596. TTY:
1-855-889-4325

If you qualify for a hardship exemption, you can buy a "catastrophic" health plan
A "catastrophic" health plan offers lower-priced coverage that mainly protects you from high medical costs if you get seriously hurt or injured. If you get a
hardship exemption, you can buy a catastrophic plan. You’re not required to buy a catastrophic plan, it’s just an option so you can get low-priced health
coverage if you want to.
• If your hardship exemption application is approved, the letter you get will include information on catastrophic health plans. For more information, visit
Healthcare.gov/choose-a-plan/plans-categories/#catastrophic or call 1-800-318-2596. (TTY:1-855-889-4325)
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.

FFM-AFFORDABILITY 1.06

Page 7 of 7

Help with your 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 or remove your Authorized Representative, contact the Marketplace. If you’re a legally appointed
representative for someone on this application, submit proof with the application.
1. First name

Middle name

Last name

Suffix

3. Apartment or suite number

2. Address

5. State

4. City

6. ZIP code

7. Phone number (###-###-####)

8. Organization name (if applicable)

9. ID number (if applicable)

By signing in block #10 below, you allow the person on this form to sign your application, get official information about this application, and act
for you on all future matters related to this application. The person who signs this form, in block #10 below, must be an adult over the age of 18
who files the federal income tax return for the household.
11. Date signed (mm/dd/yyyy)

10. Signature of tax filer

For certified application counselors, navigators, agents, and brokers only
Complete this section only 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 (if applicable)

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

FFM-AFFORDABILITY 1.06

File Type	application/pdf
File Title	Health Insurance Marketplace - Application for exemption for Individuals who are Unable to Afford Coverage and are in a State wi
Subject	Health Insurance Marketplace, Application for Exemption, Shared Responsibility Payment for Individuals, Experienced Hardships
Author	Health Insurance Marketplace
File Modified	2019-10-02
File Created	2019-08-20