CMS-10466 Exemption Application - Shared Responsibility SBM's

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

CMS-10466 - Appendix D - Affordability-SBE-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⚠️ Notice: This form may be outdated.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 State-based 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 6" 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?

• Use this application to ask for an exemption for months in the future. If you want this

What you need to

• Employer and income information for everyone in your tax household.

apply

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.

• 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 4 for examples of documents you can send. Income documents
must not be older than two years.
• The Lowest-cost Exchange Metal Level Plan (LCEMP) premium and any advanced
premium tax credit from your state's Marketplace website.

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

• 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 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

SBM-AFFORDABILITY 1.04

Page 1 of 6

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 California, Colorado, the District of Columbia, Idaho, Massachusetts, Minnesota, Nevada, New
York, Rhode Island, Vermont, or Washington?
YES. Fill out this application.
NO. Download the FFM-Affordability exemption application if you live in a state not listed above.
You need to submit a different application if 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.

Use your legal name
1. First name

Middle name

Last name

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

3. Apartment or suite number

4. City

5. State

8. Mailing address

Suffix

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 in 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 in 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.

SBM-AFFORDABILITY 1.04

Page 2 of 6

STEP 2: PERSON 1 (Start with yourself)

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)

Relationship
to Person 1
#
(spouse or
dependent)

First name

Date of birth

Last name

(mm/dd/yyyy)

Social Security
number
(###-##-####)

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

3. Yearly Income: We need to know about any income you or any other member of your tax household have made or expect to make from a job,
self-employment, unemployment, retirement, pensions, rental property, fishing/farming, alimony, and Social Security (if taxable) during the year
you want the exemption. Submit a support document with your application for each type of income listed.

First name

Last name

Total Estimated
Yearly Income

$
$
$
$
$
$
$

SBM-AFFORDABILITY 1.04

Page 3 of 6

STEP 2: Tell us about any health coverage from jobs
4. Are you or any other individuals on this application offered health coverage from a job?
Select "yes" even if that 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, select name of each person offered health coverage below and include a Health Coverage from a Job that includes the cost of the
premium for that employee and any covered family members.
NO.

STEP 3: Provide lowest cost Marketplace plan information
Unless everyone listed on this application that wants an exemption is offered health coverage from a job, you must submit this application with
two pieces of information only available through your state’s Marketplace. We can’t process your application without this information. Note: you
don’t need to provide this information if everyone listed on this application that wants an exemption is offered health coverage from a job.
1. A copy of the eligibility notice from your application to your state’s Marketplace. The notice needs to show the maximum premium tax
credit for which you qualify. If you don’t qualify for any premium tax credit, we still need the notice that shows you don't qualify.
2. Information from your state Marketplace's web page that lists the health coverage plans available for you to buy. Print and mail us a
screenshot that shows the monthly premium amount of the lowest cost exchange metal level plan you can buy. Include the plan that's
available to everyone who wants this exemption.
Note: If a single exchange metal level plan doesn’t cover everyone in your tax household who is requesting an exemption, send us the screenshots
showing the lowest-cost exchange metal level plans that, added together, have the lowest cost for everyone.
If you need help locating this information, you can visit your state's Marketplace website or call them at the number listed below:

State

Website

Phone number

California

coveredca.com

1-800-300-1506

Colorado

connectforhealthco.com

1-855-PLANS-4-YOU (1-855-752-6749)

District of Columbia

dchealthlink.com

1-855-532-5465

Idaho

yourhealthidaho.org

1-855-YH-Idaho (1-855-944-3246)

Massachusetts

mahealthconnector.org

1-877-MA-ENROLL (1-877-623-6765)

Minnesota

mnsure.org

1-855-366-7873

Nevada

nevadahealthlink.com

855-7NVLINK (855-768-5465)

New York

nystateofhealth.ny.gov

1-855-355-5777

Rhode Island

healthsourceri.com

1-855-840-HSRI (1-855-840-4774)

Vermont

healthconnect.vermont.gov

1-855-899-9600

Washington

wahealthplanfinder.org

1-855-WAFINDER (1-855-923-4633)

SBM-AFFORDABILITY 1.04

Page 4 of 6

STEP 4: 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 show the income amount you listed on your application.
If you expect your income to go up or down during the year you are 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 a self-employment ledger that includes your expected income.

Income Type

Documents

All income types

• A copy of your most recent federal income tax return, Form 1040, if your income and/or 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

• Self-employment ledger.
• Schedule C.
• Form 1120S.
• Other recent tax documents showing self-employment.
• Copy of a check for the self-employment services.

Other Income

Documents

Unemployment

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

Retirement (taxable amounts ONLY)

• 1099 or relevant tax document that list any withdrawal amounts.
• Documents 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 document 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.

SBM-AFFORDABILITY 1.04

Page 5 of 6

STEP 5: 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 (detailed or jailed)?..................................................
If yes, tell us the person's name. The name of 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 6: 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.

SBM-AFFORDABILITY 1.04

Page 6 of 6

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

SBM-AFFORDABILITY 1.04

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	2019-09-17