CMS-10466 Application Exemption - Hardships

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

CMS-10466 - Appendix B - Hardship-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⚠️ Notice: This form may be outdated.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 a Hardship Exemption
Use this
application to
apply for a
hardship
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 a category of exemptions called "hardships" available through
the Marketplace.
• 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 a hardship
exemption.
• For more information on catastrophic health plans, please see "Step 4" of this
application.

Who can use this
application?

For 2018, use this application if you or anyone in your tax household
experiences a hardship that keeps you from getting health coverage.
See page 1 (following) for the list of hardships.
• You can use one application for multiple people in your tax household.
• List everyone on your 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 experiences a hardship and you want to enroll in a
catastrophic plan.

What you need to
apply

• You can provide documents or a written explanation to support your
claim of hardship. See the table below for document examples.

Why do we ask
for this
information?

• 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.

Get help with this ••
application

• 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

HARDSHIP 1.05

Page 1 of 6

Hardship categories and documentation
Hardship
number

Category

Examples of documentation

You were homeless.

None

You were evicted or were facing eviction or
foreclosure.

Eviction or foreclosure notice. The document must show that the event happened
in this calendar year or up to two calendar years prior.

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

Shut off notice from an electric, water/sewer, or gas utility company that says
service has been or will be shut off. The document must show that the shut off
happened in this calendar year or up to two calendar years prior.

You recently experienced domestic violence.

None

You experienced the death of a close family
member.

Death certificate, death notice from newspaper, funeral service program, funeral
expenses, coroner's report, military notification of death, or other official notice
of death. The document must show that the death happened in this calendar
year or up to two calendar years prior.

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

Police or fire report, insurance claim, or other document from a government
agency or news source about the disaster. The document must show that the
event happened in this calendar year or up to two calendar years prior.

You filed for bankruptcy.

Bankruptcy filing document from a court or other legal authority. The document
must show that the bankruptcy happened in this calendar year or up to two
calendar years prior.

You had medical expenses you couldn't pay.

One or more medical bills. The bill(s) must be for this calendar year or up to two
calendar years prior.

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

Receipts for bills or services related to a family member's care, like medical bills,
home care services, or transportation receipts. The receipts must be from this
calendar year or up to two calendar years prior.

A child you expected to claim as a tax
dependent has been denied coverage in
Medicaid and the Children’s Health
Insurance Program (CHIP), and another
person is required by court order to provide
health coverage to the child.

Court order that covers the time period for which you want the exemption for the
child and copy of eligibility notice that shows the child was denied Medicaid and
CHIP coverage from your state. The Medicaid/CHIP document must show
eligibility determination for this calendar year or up to two calendar years prior.

As a result of a Health Insurance
Marketplace or state-based Marketplace
appeals decision, you're eligible for: 1)
enrollment in a qualified health plan
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 Marketplace plan.

Notice of appeal from the Health Insurance Marketplace or your state-based
Marketplace. The appeals notice must be from this calendar year or up to two
calendar years prior.

An adult in your tax household was
determined ineligible for Medicaid because
your state did NOT expand eligibility for
Medicaid under the Affordable Care Act.

None. This exemption is available only for the most recent calendar year.

You got a notice from a health insurance
plan you purchased on the individual market
(not job based coverage) saying your policy
was cancelled because it didn't meet
Affordable Care Act requirements and you
considered other plans unaffordable.

This category is no longer available for 2017 and future years.

You experienced a hardship NOT listed in
categories 1-13 that kept you from getting
health insurance.

Include any documentation that explains why you’re requesting a hardship
exemption NOT listed in categories 1-13. The documentation must show that the
hardship happened within this calendar year or up to two calendar years prior.

HARDSHIP 1.05

Page 2 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.

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

(Select if same as home address)

10. City

9. Apartment or suite number
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 the hardship events you experienced
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.

HARDSHIP 1.05

Page 3 of 6

STEP 2:

Tell us about your tax household and the hardship events you experienced

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

Last name

Date of birth

(mm/dd/yyyy)

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

Sex

Want
exemption?

1 Self
2
3
4
5
6
7
Select the type of hardship(s) you're applying for below. Note the date the hardship started, when it will end, or if it's ongoing. Then select each
person in your tax household that has experienced that hardship type, if everyone in your household has experienced that hardship type, select
all. Each person needs only one exemption for any given time period. You may apply for more than one hardship if the hardship events were at
different times during the year.
Type of hardship
(Select all that apply)

Tax year for which you
need this exemption

Date hardship started
(mm/dd/yyyy)

(Note: Your hardship can't start on a
date in the future)

Date hardship
ended or will end?
(mm/dd/yyyy)

Check if
ongoing

1. Homeless
2. Eviction/foreclosure
3. Shut-off notice
4. Domestic violence

HARDSHIP 1.05

Page 4 of 6

STEP 2: Tell us about your tax household and the hardship events you experienced

Type of hardship
(Select all that apply)

Tax year for which you
need this exemption

Date hardship started
(mm/dd/yyyy)

(Note: Your hardship can't start on a
date in the future)

Date hardship
ended or will end?
(mm/dd/yyyy)

Check if
ongoing

5. Death of family member
6. Disaster
7. Bankruptcy
8. Medical expenses
9. Increase in expenses to care for family member
10. Medical support for child
11. Eligibility appeals decision
12. Ineligible for Medicaid
13. Cancellation of individual coverage
14. You experienced another hardship

HARDSHIP 1.05

Page 5 of 6

STEP 3: 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.
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 6 of this application.
Print out application and have Person 1 sign.

Date signed (mm/dd/yyyy)

STEP 4: Mail completed application and documents
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.
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

HARDSHIP 1.05

Page 6 of 6

Help with 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 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

HARDSHIP 1.05

File Type	application/pdf
File Title	Health Insurance Marketplace - Application for a Hardship Exemption
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