8941 Instructions for Form 8941

Note: The draft you are looking for begins on the next page.

Caution: DRAFT—NOT FOR FILING

This is an early release draft of an IRS tax form, instructions, or publication,
which the IRS is providing for your information. Do not file draft forms and do
not rely on draft forms, instructions, and pubs for filing. We incorporate all
significant changes to forms posted with this coversheet. However, unexpected
issues occasionally arise, or legislation is passed—in this case, we will post a
new draft of the form to alert users that changes were made to the previously
posted draft. Thus, there are never any changes to the last posted draft of a
form and the final revision of the form. Forms and instructions are subject to
OMB approval before they can be officially released, so we post drafts of them
until they are approved. Drafts of instructions and pubs usually have some
additional changes before their final release. Early release drafts are at
IRS.gov/DraftForms and remain there after the final release is posted at
IRS.gov/LatestForms. Also see IRS.gov/Forms.
Most forms and publications have a page on IRS.gov: IRS.gov/Form1040 for
Form 1040; IRS.gov/Pub501 for Pub. 501; IRS.gov/W4 for Form W-4; and
IRS.gov/ScheduleA for Schedule A (Form 1040), for example, and similarly for
other forms, pubs, and schedules for Form 1040. When typing in a link, type it
into the address bar of your browser, not a Search box on IRS.gov.
If you wish, you can submit comments to the IRS about draft or final forms,
instructions, or pubs at IRS.gov/FormsComments. Include “NTF” followed by the
form or pub number (for example, “NTF1040”, “NTFW4”, “NTF501, etc.) in the
body of the message to route your message properly. We cannot respond to all
comments due to the high volume we receive and may not be able to consider
many suggestions until the subsequent revision of the product, but we will
review each “NTF” message. If you have comments on reducing paperwork and
respondent (filer) burden, with respect to draft or final forms, please respond to
the relevant information collection through the Federal Register process; for
more info, click here.

2023

Instructions for Form 8941

Department of the Treasury
Internal Revenue Service

Credit for Small Employer Health Insurance Premiums

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Partnerships, S corporations, cooperatives,

Section references are to the Internal Revenue Code
unless otherwise noted.

TIP estates, trusts, and tax-exempt eligible small

Future Developments

For the latest information about developments related to
Form 8941 and its instructions, such as legislation
enacted after they were published, go to IRS.gov/
Form8941.

Reminder

Waiver for Hawaii. Employers in Hawaii can’t claim this
credit for insurance premiums paid for health plan years
beginning after 2016. For more information, see Waiver for
Hawaii in the instructions for line A.

General Instructions

Purpose of Form

Eligible small employers (defined later) use Form 8941 to
figure the credit for small employer health insurance
premiums for tax years beginning after 2009. For tax years
beginning after 2013, the credit is only available for a
2-consecutive-tax-year credit period. The maximum credit
is generally a percentage of premiums the employer paid
during the tax year for certain health insurance coverage
the employer provided to certain employees enrolled in a
qualified health plan offered through a Small Business
Health Options Program (SHOP) Marketplace. But the
credit may be reduced by limitations based on the
employer’s full-time equivalent employees, average
annual wages, adjusted average premiums, and state
premium subsidies and tax credits.
For information about insurance plans offered

TIP through a SHOP Marketplace, go to
Healthcare.gov.

For tax-exempt eligible small employers, the
maximum credit is 35% of premiums paid, is limited to the
amount of certain payroll taxes paid, and is claimed as a
refundable credit on Form 990-T, Exempt Organization
Business Income Tax Return. A tax-exempt eligible small
employer is an eligible small employer described in
section 501(c) that is exempt from taxation under section
501(a). A tax-exempt employer not described in section
501(c) is generally not eligible to claim this credit.
However, a tax-exempt farmers’ cooperative subject to tax
under section 1381 may be able to claim the credit as a
general business credit, as discussed next.
For all other eligible small employers, the maximum
credit is 50% of premiums paid and can be taken against
both regular and alternative minimum tax. The credit is
claimed as part of the general business credit on Form
3800, General Business Credit.
Nov 8, 2023

employers must file this form to claim the credit.
All other taxpayers must not complete or file this form if
their only source for this credit is a partnership, S
corporation, cooperative, estate, or trust. Instead, they
must report this credit directly on line 4h in Part III of Form
3800, General Business Credit.

Eligible Small Employers

You’re an eligible small employer for the tax year if you
meet the following three requirements.

1. You paid premiums for employee health insurance
coverage under a qualifying arrangement. A
qualifying arrangement is generally an arrangement that
requires you to pay a uniform percentage (not less than
50%) of the premium cost for each enrolled employee’s
health insurance coverage (defined later). However, an
arrangement that requires you to pay a uniform premium
for each enrolled employee (composite billing) and offers
different tiers of coverage (for example, employee-only,
dependent, and family coverage) can be a qualifying
arrangement even if it requires you to pay a uniform
percentage that is less than 50% of the premium cost for
employees not enrolled in employee-only coverage.
In addition, an arrangement that requires you to pay a
separate premium for each employee based on age or
other factors (list billing) can be a qualifying arrangement
even if it requires you to pay a uniform percentage that is
less than 50% of the premium cost for some employees.
For details, see Employer Premiums Paid, Health
Insurance Coverage, and Qualifying Arrangement, later.

2. You had fewer than 25 full-time equivalent employees (FTEs) for the tax year. You may be able to meet
this requirement even if you had 25 or more employees.
For example, an employer with 48 employees who are
each half-time employees has 24 FTEs and can claim the
credit. For details, see Worksheets 1 and 2.
Although the term “eligible small employer” is
defined in the Internal Revenue Code to include
CAUTION employers with “no more than” 25 FTEs, the
phaseout of the credit amount operates in such a way that
an employer with exactly 25 FTEs is not, in fact, eligible for
the credit.

!

3. You paid average annual wages for the tax year of
less than $62,000 per FTE. For details, see Worksheets
1 and 3.

Cat. No. 55222U

If you had more than 10 FTEs and average annual
wages of more than $30,000, the FTE and
CAUTION average annual wage limitations (discussed later)
will separately reduce your credit. This may reduce your
credit to zero even if you had fewer than 25 FTEs and
average annual wages of less than $62,000.

State premium subsidy or tax credit. If you’re entitled
to a state tax credit or a state premium subsidy paid
directly to you for premiums you paid, don’t reduce the
amount you paid by the credit or subsidy amount. Also, if a
state pays a premium subsidy directly to your insurance
provider, treat the subsidy amount as an amount you paid
for employee health insurance coverage.

!

Employers treated as a single employer. Treat the
following employers as a single employer to figure the
credit.
• Employers who are corporations in a controlled group of
corporations.
• Employers who are members of an affiliated service
group.
• Employers who are partnerships, proprietorships, etc.,
under common control. See Regulations sections
1.414(c)-2, 1.414(c)-3, and 1.414(c)-4.
• Tax-exempt employers under common control. See
Regulations section 1.414(c)-5.
For details, see section 45R(e)(5)(A) and Regulations
section 1.45R-2(b).

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Wellness programs. A wellness program is generally an
insurance program of health promotion or disease
prevention. If you pay part or all of the cost of an
employee’s participation in a wellness program, treat the
amount you paid toward the employee’s participation as
an amount you paid for employee health insurance
coverage.

Tobacco surcharges. A tobacco surcharge is generally
an additional amount charged for insurance for a tobacco
user. If you pay part or all of an employee’s tobacco
surcharge, you can’t use the amount you paid to figure
your employer premiums paid.

Dependent coverage. Dependent coverage is generally
coverage offered separately to an individual who is or may
become eligible for coverage under the terms of a group
health plan because of a relationship to a
participant-employee, whether or not a dependent of the
participant-employee. Dependent coverage doesn’t
include coverage, such as family coverage, which
includes coverage of the participant-employee. If you pay
part or all of the cost of an employee’s dependent
coverage, use the amount you paid to figure your
employer premiums paid.

No more than one Form 8941 can be filed with a
TIP tax return, unless the exception described in
Example 2 below applies.

Example 1. You’re a sole proprietor with two separate
businesses and you file a separate Schedule C (Form
1040), Profit or Loss From Business, for each business.
You must treat both businesses as a single employer to
figure the credit. You will file one Form 8941 for both
businesses.

Example 2. You and your spouse are both sole
proprietors and file a separate Schedule C (Form 1040)
for each of your separate businesses. Neither spouse was
an employee of the other spouse or participated in the
management of the other spouse’s business at any time
during the tax year. No more than 50% of the gross
income of either business was derived from royalties,
rents, dividends, interest, and annuities and you otherwise
meet the requirements listed in Regulations section
1.414(c)-4(b)(5)(ii). Don’t treat both businesses as a
single employer to figure the credit. If you and your spouse
are both eligible small employers, you can file two Forms
8941 with a jointly filed Form 1040 or 1040-SR.

Portion of premiums paid. If you pay only a portion of
the premiums and your employees pay the rest, only the
portion you pay is taken into account. For this purpose,
any premium paid through a salary reduction arrangement
under a section 125 cafeteria plan isn’t treated as an
employer paid premium. For more information on cafeteria
plans, see section 1 of Pub. 15-B, Employer’s Tax Guide to
Fringe Benefits.
Example 3. You offer health insurance coverage to
employees under a qualifying arrangement that requires
you to pay 60% of the premium cost for employee-only
coverage for each employee enrolled in any health
insurance coverage you provide to employees. The total
premium for each employee enrolled in employee-only
coverage is $5,200 per year or $100 ($5,200 ÷ 52) for
each weekly payday. The total premium for each
employee enrolled in family coverage is $13,000 per year
or $250 ($13,000 ÷ 52) for each weekly payday.
Each payday, you contribute $60 (60% of $100) toward
the premium cost of each employee enrolled in
employee-only coverage and withhold the remaining $40
from the employee's paycheck to obtain the $100 total
weekly premium. Each payday, you contribute $60 (the
same amount you pay toward the premiums of employees
enrolled in employee-only coverage) toward the premium
cost of each employee enrolled in family coverage and
withhold the remaining $190 from the employee’s
paycheck to obtain the $250 total weekly premium.
To determine the premiums you paid during the tax
year, multiply the number of pay periods during which the

Credit Period

For tax years beginning after 2013, the credit period
during which the credit can be claimed is a
2-consecutive-tax-year period beginning with the first tax
year in which:
• An eligible small employer (or any predecessor) files an
income tax return with an attached Form 8941 with line A
checked “Yes” and a positive amount on line 12, or
• A tax-exempt eligible small employer (or any
predecessor) files Form 990-T with an attached Form
8941 with line A checked “Yes” and a positive amount on
line 12.

Employer Premiums Paid

Only premiums you paid for health insurance coverage
under a qualifying arrangement (discussed later) for
individuals considered employees are counted when
figuring your credit.
-2-

Instructions for Form 8941 (2023)

surcharge for nonparticipation). However, for purposes of
figuring the credit, the employer contributions are taken
into account, including those contributions attributable to
an employee’s participation in a wellness program.

employee was enrolled in the health insurance coverage
by $60. For example, you would’ve paid $3,120 ($60 × 52)
for an employee who was enrolled for the entire tax year.
You would’ve paid $600 ($60 × 10) for an employee who
was only enrolled for 10 pay periods. You will need an
additional set of calculations if the premium amounts
changed during the tax year.

Tobacco surcharge. Any additional amount you or your
employee pays to cover a tobacco surcharge isn’t taken
into account in figuring the uniform percentage
requirement. Amounts you or your employee pays to cover
a tobacco surcharge aren’t considered premiums paid for
health insurance coverage when figuring this credit.

Health Insurance Coverage

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
For tax years beginning after 2013, health insurance
coverage generally means coverage provided to
employees enrolled in a qualified health plan offered
through a Small Business Health Options Program
(SHOP) Marketplace. For an exception that applies to
certain employers in certain counties, see the instructions
for line A, later. If this exception applies, health insurance
coverage means coverage, as defined under Health
Insurance Coverage in the 2013 Instructions for Form
8941.

Dependent coverage. Premiums you pay for dependent
coverage aren’t subject to the uniform percentage
requirement. You aren’t required to pay a uniform
percentage (not less than 50%) for dependent coverage.

Arrangements with composite billing. An arrangement
that requires you to pay a uniform premium for each
enrolled employee (composite billing) and offers different
tiers of coverage can be a qualifying arrangement even if it
requires you to pay a uniform percentage that is less than
50% of the premium cost for employees not enrolled in
employee-only coverage. It is a qualifying arrangement
(assuming employee-only coverage is the least expensive
tier of coverage) if it requires you to pay each of the
following amounts if you make the relevant tier of coverage
available.
• A uniform percentage (not less than 50%) of the
premium cost for each employee (if any) enrolled in
employee-only coverage.
• A uniform amount that is no less than the amount you
would’ve paid toward employee-only coverage for each
employee (if any) enrolled in family coverage.
• A uniform amount that is no less than the amount you
would’ve paid toward employee-only coverage for each
employee (if any) enrolled in any other tier of coverage
(figured separately for each tier).

A stand-alone dental plan offered through a SHOP

TIP exchange will be considered a qualified health
plan for purposes of the credit.

Employer premiums paid for health insurance
coverage can be counted in figuring the credit only
CAUTION if the premiums are paid under a qualifying
arrangement.

!

Qualifying Arrangement

A qualifying arrangement is generally an arrangement that
requires you to pay a uniform percentage (not less than
50%) of the premium cost for each enrolled employee's
health insurance coverage (defined earlier). An
arrangement that offers different tiers of coverage (for
example, employee-only and family coverage) is generally
a qualifying arrangement if it requires you to pay a uniform
percentage (not less than 50%) separately for each tier of
coverage you offer. However, an arrangement can be a
qualifying arrangement even if it requires you to pay a
uniform percentage that is less than 50% of the premium
cost for some employees.

Arrangements with list billing and only employee-only coverage. An arrangement that requires you to pay a
separate premium for each employee based on age or
other factors (list billing) that only provides employee-only
coverage can be a qualifying arrangement even if it
requires you to pay a uniform percentage that is less than
50% of the premium cost for some employees. It is a
qualifying arrangement if it requires you to pay either of
the following amounts.
• A uniform percentage (not less than 50%) of the
premium charged for each employee enrolled in the
employee-only coverage.
• A uniform percentage (not less than 50%) of your
employer-computed composite rate (defined later) for your
employee-only coverage for each employee enrolled in
the employee-only coverage.

For more information about the following exceptions,
see Regulations section 1.45R-4.
State or local law. You will be treated as satisfying the
uniform percentage requirement if your failure to otherwise
satisfy the requirement was solely attributable to
additional contributions you made to certain employees to
comply with state or local law.
Wellness program. If a plan of an employer provides a
wellness program, for purposes of meeting the uniform
percentage requirement, the following applies. Any
additional amount of the employer contribution attributable
to an employee’s participation in the wellness program
over the employer contribution with respect to an
employee that doesn’t participate in the wellness program
isn’t considered in calculating the uniform percentage
requirement. This is true whether the difference is due to a
discount for participation or a surcharge for
nonparticipation. The employer contribution for employees
who don’t participate in the wellness program must be at
least 50% of the premium (including any premium
Instructions for Form 8941 (2023)

Arrangements with list billing and other tiers of coverage. An arrangement that requires you to pay a
separate premium for each employee based on age or
other factors (list billing) that provides other tiers of
coverage can be a qualifying arrangement even if it
requires you to pay a uniform percentage that is less than
50% of the premium cost for some employees. It is a
qualifying arrangement (assuming employee-only
coverage is the least expensive tier of coverage) if it
-3-

Net premium payments are employer premiums paid
(discussed earlier) minus the amount of any state tax
credits you received or will receive and any state premium
subsidies paid either to you or directly to your insurance
provider for premiums for health insurance coverage you
provide under a qualifying arrangement to individuals
considered employees.

requires you to pay each of the following amounts if you
make the relevant tier of coverage available.
• A uniform percentage (not less than 50%) for each
employee enrolled in employee-only coverage, as
discussed under Arrangements with list billing and only
employee-only coverage, earlier.
• A uniform amount that is either equal to the amount you
would’ve paid toward employee-only coverage (as
discussed above), a uniform percentage (not less than
50%) of the premium charged, or a uniform percentage
(not less than 50%) of your employer-computed
composite rate (defined below) for your family coverage,
for each employee (if any) enrolled in family coverage.
• A uniform amount that is either equal to the amount you
would’ve paid toward employee-only coverage (as
discussed above), a uniform percentage (not less than
50%) of the premium charged, or a uniform percentage
(not less than 50%) of your employer-computed
composite rate (defined below) for any other tier of
coverage, for each employee (if any) enrolled in any other
tier of coverage (figured separately for each tier).

Payroll Tax Limitation for Tax-Exempt
Eligible Small Employers

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
The credit for tax-exempt eligible small employers can’t
exceed the amount of certain payroll taxes. For tax years
beginning in 2023, payroll taxes, for this purpose, mean
only the following taxes.
• Federal income taxes the tax-exempt employer was
required to withhold from employees’ wages in calendar
year 2023.
• Medicare taxes the tax-exempt employer was required
to withhold from employees’ wages in calendar year 2023.
• Medicare taxes the tax-exempt employer was required
to pay for calendar year 2023.

Employer-computed composite rate. The
employer-computed composite rate for a tier of coverage
is the average rate determined by adding the premiums for
that tier of coverage for all employees eligible to
participate in the health insurance plan (whether or not
they actually receive coverage under the plan or under
that tier of coverage) and dividing by the total number of
such eligible employees.

Premium Deduction Reduced

You must reduce your deduction for the cost of providing
health insurance coverage to your employees by the
amount of any credit for small employer health insurance
premiums allowed with respect to the coverage.

More Information

For more information about this credit, see the following.
• Section 45R.
• Regulations sections 1.45R-0 through 1.45R-5.
• IRS.gov/Affordable-Care-Act/Employers/SmallBusiness-Health-Care-Tax-Credit-and-the-SHOPMarketplace.

More than one plan. Different types of health insurance
plans are generally not aggregated for purposes of
meeting the qualifying arrangement requirement. For
example, if you offer a major medical insurance plan and a
stand-alone vision plan, you generally must separately
satisfy the requirements for a qualifying arrangement with
respect to each type of coverage. For exceptions, see
Regulations section 1.45R-4(c).

Specific Instructions

State subsidies and credits. For this purpose, if you’re
entitled to a state tax credit or a state premium subsidy
paid directly to you for premiums you paid, don’t reduce
the amount you paid by the credit or subsidy amount.
Also, if a state pays a premium subsidy directly to your
insurance provider, treat the subsidy amount as an
amount you paid for employee health insurance coverage.

Partnerships, S corporations, cooperatives,

TIP estates, trusts, and tax-exempt eligible small

employers must file this form to claim the credit.
All other taxpayers must not complete or file this form if
their only source for this credit is a partnership, S
corporation, cooperative, estate, or trust. Instead, they
must report this credit directly on line 4h in Part III of Form
3800.

State Premium Subsidy and Tax
Credit Limitation

Use Worksheets 1 through 7 to figure the amounts to
report on various lines of Form 8941.
• Use Worksheets 1, 2, and 3 to figure the amounts to
report on lines 1, 2, and 3 of Form 8941.
• Use Worksheet 4 to figure the amounts to report on
lines 4, 5, and 13 of Form 8941.
• Use Worksheets 5, 6, and 7 to figure the amounts to
report on lines 8, 9, and 14 of Form 8941.

Your credit may be reduced if you’re entitled to a state tax
credit or a state premium subsidy for the cost of health
insurance coverage you provide under a qualifying
arrangement to individuals considered employees. The
state tax credit may be refundable or nonrefundable and
the state premium subsidy may be paid to you or directly
to your insurance provider.

Line A

Although a state tax credit or premium subsidy paid
directly to you doesn’t reduce the amount of your
employer premiums paid, and although a state premium
subsidy paid directly to an insurance provider is treated as
an employer premium you paid, the amount of your credit
can’t be more than your net premium payments.

Answer “Yes” if one of the following applies.
• You paid premiums for employee health insurance
coverage you provided through a SHOP Marketplace or
through a direct enrollment process, if available in your
state.

-4-

Instructions for Form 8941 (2023)

• You qualify for an exception to this requirement, as
discussed below.

Worksheet 1. Information Needed To
Complete Line 1 and Worksheets 2
and 3

If you answer “Yes” because you paid premiums for
employee health insurance coverage you provided
through a SHOP Marketplace, enter the Marketplace
identifier, if any.

If you need more rows, use a separate sheet and include
the additional amounts in the totals below.

If you answer “No,” don’t file Form 8941 unless you’re
filing it for a partnership, S corporation, cooperative,
estate, trust, or tax-exempt eligible small employer that
received from another entity a credit that must be reported
on line 15. For more information, see the instructions for
line 15.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
(a)
Individuals
Considered
Employees

(b)
Employee
Hours of
Service

(c)
Employee
Wages
Paid

 1.

Waiver for Hawaii. Hawaii has received a 5-year State
Innovation Waiver under section 1332 of the Affordable
Care Act that has been extended for 5 more years.
Employers in Hawaii can’t participate in the SHOP
Marketplace or claim the credit for insurance premiums
paid for health plan years beginning after 2016. For more
information on the waiver, go to CMS.gov.

 2.
 3.
 4.
 5.
 6.

Exception for eligible small employers in certain
counties. For calendar year 2023, SHOP Marketplaces
in certain counties across the United States didn’t have
qualified health plans available for employers to offer to
employees. However, relief is available, which allows
eligible small employers with a principal business address
in those counties to claim the credit for 2023 if they
properly claimed the credit under section 45R for all or
part of 2022. For details, see Notice 2018-27, 2018-20,
I.R.B. 580, available at IRS.gov/irb/
2018-20_IRB#NOT-2018-27.

 7.
 8.
 9.
10.
11.
12.
13.
14.

To see whether a particular county has coverage

15.

TIP available through a SHOP Exchange for 2023 and

16.

beyond, go to Healthcare.gov/small-business and
enter “plans and prices” in the search box.

17.
18.

Line C

19.

Answer “Yes” if a tax return you (or any predecessor) filed
for a tax year beginning after 2013 and before 2022
included a Form 8941 with line A checked “Yes” and
line 12 showing a positive amount. For more information,
see Credit Period, earlier.

20.
21.
22.
23.

If you answer “Yes,” don’t file Form 8941 unless you’re
filing it for a partnership, S corporation, cooperative,
estate, trust, or tax-exempt eligible small employer that
received from another entity a credit that must be reported
on line 15. An entity that qualifies for this exception
shouldn’t report any amount on line 12. For more
information, see the instructions for line 15.

24.
25.
Totals:

Column (a), Individuals Considered
Employees

Enter the name or other identifying information for all
individuals considered employees for purposes of this
credit.

In general, all employees who perform services for you
during the tax year are taken into account in determining
your FTEs, average annual wages, and premiums paid.
Rules that apply to certain types of employees are
discussed below.
Instructions for Form 8941 (2023)

-5-

discussed above. A sole proprietor must include both
business and nonbusiness employees to determine FTEs,
average annual wages, and premiums paid.

Excluded employees. The following individuals aren’t
considered employees when you figure this credit. Hours
and wages of these employees and premiums paid for
them aren’t counted when you figure your credit.
• The owner of a sole proprietorship.
• A partner in a partnership.
• A shareholder who owns (after applying the section 318
constructive ownership rules) more than 2% of an S
corporation.
• A shareholder who owns (after applying the section 318
constructive ownership rules) more than 5% of the
outstanding stock or stock possessing more than 5% of
the total combined voting power of all stock of a
corporation that isn’t an S corporation.
• A person who owns more than 5% of the capital or
profits interest in any other business that isn’t a
corporation.
• Family members or a member of the household who
isn’t a family member but qualifies as a dependent on the
individual income tax return of a person listed above.
Family members include a child (or descendant of a
child), a sibling or step-sibling, a parent (or ancestor of a
parent), a step-parent, a niece or nephew, an aunt or
uncle, or a son-in-law, daughter-in-law, father-in-law,
mother-in-law, brother-in-law, or sister-in-law. A spouse of
any owner or family member listed above is also
considered a family member for this purpose.

Ministers. A minister performing services in the exercise
of the minister’s ministry is treated as self-employed for
social security and Medicare purposes. However, for
credit purposes, whether a minister is an employee or
self-employed is determined under the common law test
for determining worker status. Self-employed ministers
aren’t considered employees.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Column (b), Employee Hours of
Service

Enter the total hours of service for the tax year for each
employee listed in column (a). Don’t enter more than
2,080 hours for any employee. But enter -0- for seasonal
employees who worked 120 or fewer days during the tax
year.

Employee hours of service. An employee’s hours of
service for a year include the following.
• Each hour for which the employee is paid, or entitled to
payment, for the performance of duties for the employer
during the employer’s tax year.
• Each hour for which an employee is paid, or entitled to
payment, by the employer on account of a period of time
during the employer’s tax year during which no duties are
performed due to vacation, holiday, illness, incapacity
(including disability), layoff, jury duty, military duty, or leave
of absence (except that no more than 160 hours of service
are required to be counted for an employee on account of
any single continuous period during which the employee
performs no duties).
To figure the total number of hours of service you must
take into account for an employee for the year, you can
use any of the following methods.
Actual-hours-worked method. Determine actual
hours of service from records of hours worked and hours
for which payment is made or due (payment is made or
due for vacation, holiday, illness, incapacity, etc., as
described above).
Days-worked equivalency method. Use a
days-worked equivalency whereby the employee is
credited with 8 hours of service for each day for which the
employee would be required to be credited with at least 1
hour of service under the rules described above.
Weeks-worked equivalency method. Use a
weeks-worked equivalency whereby the employee is
credited with 40 hours of service for each week for which
the employee would be required to be credited with at
least 1 hour of service under the rules described above.

Former employees. Premiums paid on behalf of a
former employee with no hours of service may be treated
as paid on behalf of an employee for purposes of figuring
the credit, provided that, if so treated, the former
employee is also treated as an employee for purposes of
the uniform percentage requirement.

Leased employees. Don’t use premiums paid by the
leasing organization to figure your credit. Also, a leased
employee who isn’t a common law employee is
considered an employee for credit purposes if the
employee does all the following.
• Provides services to you under an agreement between
you and a leasing organization.
• Has performed services for you (or for you and a related
person) substantially full time for at least 1 year.
• Performs services under your primary direction or
control.
But don’t use hours, wages, or premiums paid with
respect to the initial year of service on which leased
employee status is based.
Seasonal employees. Employees who perform labor or
services on a seasonal basis and perform labor or
services for you 120 or fewer days during the tax year
aren’t considered employees in determining FTEs and
average annual wages. But premiums paid on their behalf
are counted in determining the amount of the credit.
Seasonal workers include retail workers employed
exclusively during holiday seasons. Seasonal workers
also include workers employed exclusively during the
summer.

Column (c), Employee Wages Paid

!

CAUTION

Complete Worksheet 2 before you complete
column (c) of Worksheet 1. Do not complete
column (c) if Worksheet 2, line 3, is 25 or more.

Enter the total wages paid for the tax year for each
employee listed in column (a). But enter -0- for seasonal
employees who worked 120 or fewer days during the tax
year.

Household and other nonbusiness employees.
Household employees and other employees who aren’t
performing services in your trade or business are
considered employees if they otherwise qualify, as
-6-

Instructions for Form 8941 (2023)

Worksheet 4. Information Needed To
Complete Lines 4, 5, and 13 and
Worksheet 7

Wages, for this purpose, mean wages subject to social
security and Medicare tax withholding determined without
considering any wage base limit.

Worksheet 2. Information Needed To
Complete Line 2 (FTEs)

If you need more rows, use a separate sheet and include
the additional amounts in the totals below.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Your credit is reduced if you had more than 10 FTEs for
the tax year. If you had 25 or more FTEs for the tax year,
your credit is reduced to zero.
1. Enter the total employee hours of
service from Worksheet 1, column
(b) . . . . . . . . . . . . . . . . . . . . . . . . .

1.

2. Hours of service per FTE . . . . . . . . .

2.

3. Full-time equivalent employees.
Divide line 1 by line 2. If the result isn’t a
whole number (0, 1, 2, etc.), generally
round the result down to the next
lowest whole number. For example,
round 2.99 down to 2. However, if the
result is less than one, enter 1. Report
this number on Form 8941, line 2 . . .

(a)
Enrolled
Individuals
Considered
Employees

(c)
Adjusted
Average
Premiums

(d)
Enrolled
Employee
Hours of
Service

 1.

2,080

 2.
 3.
 4.
 5.
 6.
 7.

3.

 8.

Worksheet 3. Information Needed To
Complete Line 3 (Average Annual
Wages)

 9.

Your credit is reduced if you paid average annual wages of
more than $30,000 for the tax year. If you paid average
annual wages of $62,000 or more for the tax year, your
credit is reduced to zero.

13.

1. Enter the total employee wages paid
from Worksheet 1, column (c) . . . . . .

1.

2. Enter FTEs from Worksheet 2,
line 3 . . . . . . . . . . . . . . . . . . . . . . .

2.

3. Average annual wages. Divide line 1
by line 2. If the result isn’t a multiple of
$1,000 ($1,000, $2,000, $3,000, etc.),
round the result down to the next
lowest multiple of $1,000. For example,
round $2,999 down to $2,000. Report
this amount on Form 8941, line 3 . . .

(b)
Employer
Premiums
Paid

10.
11.
12.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.

3.

24.
25.
Totals:

Column (a), Enrolled Individuals
Considered Employees

Enter the name or other identifying information for each
individual listed in column (a) of Worksheet 1 who was
enrolled in health insurance coverage you provided to
employees during the tax year under a qualifying
arrangement. For details, see Health Insurance Coverage
and Qualifying Arrangement, earlier.

Instructions for Form 8941 (2023)

-7-

Column (b), Employer Premiums Paid

enrolled for the entire tax year. You would’ve paid $570
($57 × 10) if the employee was only enrolled for 10 pay
periods. You’ll need an additional set of calculations if the
premium amounts changed during the tax year.

Enter the total employer premiums paid for the tax year for
each employee listed in column (a). For details, see
Employer Premiums Paid, earlier.

Column (d), Enrolled Employee Hours
of Service

Column (c), Adjusted Average
Premiums

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Your credit is reduced if the employer premiums paid are
more than the employer premiums that would’ve been
paid if individuals considered employees were enrolled in
a plan with a premium equal to the average premium for
the small group market in the rating area in which the
employee enrolls for coverage.

!

Don’t complete column (d) of Worksheet 4 if Form
8941, line 12, is zero.

CAUTION

Enter the amount from column (b) of Worksheet 1 for
each employee listed in column (a) of Worksheet 4.

Worksheet 5. Information Needed To
Complete Line 8 (If Line 2 Is More
Than 10)

The rating area in which an employee enrolls for
coverage is generally the rating area where your business
is located (based on your primary business address). You
will generally have selected a plan in your rating area that
covers all employees located within or outside your rating
area. However, if you have multiple businesses or
operations in multiple states, and have set up plans in
more than one SHOP Marketplace, the average premiums
may be different for employees enrolled in each SHOP
Marketplace.

1. Enter the amount from Form 8941,
line 7 . . . . . . . . . . . . . . . . . . . . . . . . . .

Enter, for each employee listed in column (a), the
premiums you would’ve paid if the employee had enrolled
in a plan or plans with a total premium equal to the
average premium for the small group market in the rating
area in which the employee enrolls for coverage.

To find the average premium for the small group market
in a rating area for tax years beginning in 2023, see the
average premium tables at the end of these instructions.
Family coverage includes any coverage other than
employee-only coverage.

2. Enter the number from Form
8941, line 2 . . . . . . . . . . . .

2.

3. Subtract 10 from line 2 . . . . .

3.

4. Divide line 3 by 15. Enter the
result as a decimal (rounded to
at least 3 places) . . . . . . . .

4.

1.

5. Multiply line 1 by line 4 . . . . . . . . . . . . . .

5.

6. Subtract line 5 from line 1. Report this
amount on Form 8941, line 8 . . . . . . . . .

6.

Worksheet 6. Information Needed To
Complete Line 9 (If Line 3 Is More
Than $30,000)

Example 4. Assume the same facts that were used in
Example 3. The $60 you contribute each payday toward
employee health insurance coverage is 60% ($60 ÷ $100)
of the weekly premium for each employee enrolled in
employee-only coverage and 24% ($60 ÷ $250) of the
weekly premium for each employee enrolled in family
coverage.
In this situation, the total average premium limitation
amounts that apply are 60% of the applicable average
premium amounts for each employee enrolled in
employee-only coverage and 24% of the applicable
average premium amounts for each employee enrolled in
family coverage.
You have an employee enrolled in employee-only
coverage who enrolled for coverage in your local rating
area. The applicable employee-only average premium
amount for the rating area is $4,940 or $95 ($4,940 ÷ 52)
for each weekly payday. The amount you would’ve paid
toward this employee’s health insurance coverage based
on the average premiums is $57 (60% of $95) each
payday.
To determine the premiums you would’ve paid for this
employee during the tax year if the employee had enrolled
in an average premium plan, multiply the number of pay
periods during which your employee was enrolled in the
health insurance coverage by $57. For example, you
would’ve paid $2,964 ($57 × 52) if the employee was

1. Enter the amount from Form 8941,
line 8 . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Enter the amount from Form
8941, line 7 . . . . . . . . . . . . .

2.

3. Enter the amount from Form
8941, line 3 . . . . . . . . . . . . .

3.

4. Subtract $30,700 from line 3

4.

.

5. Divide line 4 by $30,700. Enter
the result as a decimal (rounded
to at least 3 places) . . . . . . . .

1.

5.

6. Multiply line 2 by line 5 . . . . . . . . . . . . . .

6.

7. Subtract line 6 from line 1. Report this
amount on Form 8941, line 9 . . . . . . . . .

7.

Line 10

Enter the total amount of any state premium subsidies
paid and any state tax credits available to you for
premiums included on line 4. For details, see State
Premium Subsidy and Tax Credit Limitation, earlier.

-8-

Instructions for Form 8941 (2023)

Worksheet 7. Information Needed To
Complete Line 14 (If Line 12 Is More
Than Zero)

its tax liability. Therefore, to figure the unused amount of
the credit allocated to patrons, the cooperative must first
figure its tax liability. While any excess is allocated to
patrons, any credit recapture applies as if the cooperative
had claimed the entire credit.
If the cooperative is subject to the passive activity rules,
include on line 15 any credit for small employer health
insurance premiums from passive activities disallowed for
prior years and carried forward to this year. Complete
Form 8810, Corporate Passive Activity Loss and Credit
Limitations, to determine the allowed credit that must be
allocated to patrons. For details, see the Instructions for
Form 8810.

1. Enter the total enrolled employee hours of
service from Worksheet 4, column
(d) . . . . . . . . . . . . . . . . . . . . . . . . . .
1.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
2. Hours of service per FTE . . . . . . . . . .

2.

2,080

3. Divide line 1 by line 2. If the result isn’t a
whole number (0, 1, 2, etc.), generally
round the result down to the next
lowest whole number. For example, round
2.99 down to 2. However, if the result is
less than one, enter 1. Report this
number on Form 8941, line 14 . . . . . .
3.

Estates and trusts. Allocate the credit on line 16
between the estate or trust and the beneficiaries in the
same proportion as income was allocated and enter the
beneficiaries’ share on line 17.
If the estate or trust is subject to the passive activity
rules, include on line 15 any credit for small employer
health insurance premiums from passive activities
disallowed for prior years and carried forward to this year.
Complete Form 8582-CR, Passive Activity Credit
Limitations, to determine the allowed credit that must be
allocated between the estate or trust and the
beneficiaries. For details, see the Instructions for Form
8582-CR.

Line 15

Enter any credit for small employer health insurance
premiums from:
• Schedule K-1 (Form 1065), Partner's Share of Income,
Deductions, Credits, etc., box 15 (code BA);
• Schedule K-1 (Form 1120-S), Shareholder's Share of
Income, Deductions, Credits, etc., box 13 (code BA);
• Schedule K-1 (Form 1041), Beneficiary’s Share of
Income, Deductions, Credits, etc., box 13 (code G); and
• Form 1099-PATR, Taxable Distributions Received From
Cooperatives, box 12, or other notice of credit allocation.

Line 19

Enter the total amount of certain payroll taxes. Payroll
taxes, for this purpose, mean only the following taxes.
• Federal income taxes the tax-exempt employer was
required to withhold from employees’ wages in calendar
year 2023.
• Medicare taxes the tax-exempt employer was required
to withhold from employees’ wages in calendar year 2023.
• Medicare taxes the tax-exempt employer was required
to pay for calendar year 2023.

Partnerships, S corporations, cooperatives,
TIP estates, trusts, and tax-exempt eligible small
employers report the above credits on line 15. All
other filers figuring a separate credit on earlier lines also
report the above credits on line 15. All others not using
earlier lines to figure a separate credit must report the
above credits directly on Form 3800, Part lll, line 4h.

Line 17
Cooperatives. A cooperative described in section
1381(a) must allocate to its patrons the credit in excess of

Instructions for Form 8941 (2023)

-9-

Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the
United States. You are required to give us the information. We need it to ensure that you are complying with these laws
and to allow us to figure and collect the right amount of tax.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax
returns and return information are confidential, as required by section 6103.

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
h

The time needed to complete and file this form will vary depending on individual circumstances. The estimated burden
for individual and business taxpayers filing this form is approved under OMB control number 1545-0074 and 1545-0123
and is included in the estimates shown in the instructions for their individual and business income tax return. The
estimated burden for all other taxpayers who file this form is shown below.
Recordkeeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Learning about the law or the form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preparing and sending the form to the IRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8 hr., 8 min.
1 hr., 2 min.
2 hr., 5 min.

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler,
we would be happy to hear from you. See the instructions for the tax return with which this form is filed.

-10-

Instructions for Form 8941 (2023)

Average Premiums Needed To Figure Adjusted Amounts on Worksheet 4
The following tables list the average
premiums for the small group market
in each rating area generally listed by
county for each state for tax years
beginning in 2023.

Limestone

7,262

23,301

Petersburg

11,771

31,062

Lowndes

8,391

23,453

Prince of Wales-Hyder 11,771

31,062

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Alabama

Macon

7,241

20,533

Sitka

11,771

31,062

Madison

7,262

23,301

Skagway

11,771

31,062

Marengo

7,241

20,533

Southeast Fairbanks

12,011

30,930

Marion

7,241

20,533

Valdez Cordova

11,303

29,868

7,241

20,533

Wade Hampton

12,011

30,930

Wrangell City and
Borough

11,771

31,062

Yakutat

12,011

30,930

Yukon Koyukuk

12,011

30,930

County

Employee- Dependent,
Only
Family, etc.

Marshall
Mobile

7,468

22,163

Autauga

8,391

23,453

Monroe

7,241

20,533

Baldwin

7,241

20,533

Montgomery

8,391

23,453

Barbour

7,241

20,533

Morgan

7,893

19,596

Bibb

7,061

22,250

Perry

7,241

20,533

Blount

7,061

22,250

Pickens

7,241

20,533

Bullock

7,241

20,533

Pike

7,241

20,533

Butler

7,241

20,533

Randolph

7,241

20,533

Calhoun

6,836

20,924

Russell

7,210

21,092

Chambers

7,241

20,533

Shelby

7,061

22,250

Cherokee

7,241

20,533

St. Clair

7,061

22,250

Chilton

7,061

22,250

Sumter

7,241

20,533

Choctaw

7,241

20,533

Talladega

7,241

20,533

Clarke

7,241

20,533

Tallapoosa

7,241

20,533

Clay

7,241

20,533

Tuscaloosa

7,665

21,879

Cleburne

7,241

20,533

Walker

7,061

22,250

Coffee

7,241

20,533

Washington

7,241

20,533

Colbert

8,701

22,810

Wilcox

7,241

20,533

Conecuh

7,241

20,533

Winston

7,241

20,533

Coosa

7,241

20,533

Covington

7,241

20,533

Crenshaw

7,241

20,533

Cullman

7,241

20,533

County

Employee- Dependent,
Only
Family, etc.

Dale

7,241

20,533

Aleutians East

12,011

30,930

Dallas

7,241

20,533

Aleutians West

12,011

30,930

DeKalb

7,241

20,533

Anchorage

11,303

29,868

Elmore

8,391

23,453

Bethel

11,303

29,868

Escambia

7,241

20,533

Bristol Bay

12,011

30,930

Etowah

6,539

22,226

Denali

12,011

30,930

Fayette

7,241

20,533

Dillingham

11,303

29,868

Franklin

7,241

20,533

Fairbanks North Star

12,011

30,930

Geneva

7,505

22,014

Haines

11,771

31,062

Greene

7,665

21,879

Hoonah-Angoon

11,771

31,062

Hale

7,665

21,879

Juneau

11,771

31,062

Henry

7,505

22,014

Kenai Peninsula

12,011

30,930

Houston

7,505

22,014

Ketchikan Gateway

11,771

31,062

Jackson

7,241

20,533

Kodiak Island

12,011

30,930

Jefferson

7,061

22,250

Lake and Peninsula

12,011

30,930

Lamar

7,241

20,533

Matanuska Susitna

12,011

30,930

Lauderdale

8,701

22,810

Nome

12,011

30,930

Lawrence

7,893

19,596

North Slope

12,011

30,930

Lee

6,462

19,185

Northwest Arctic

12,011

30,930

2023 Average Premium Tables

Alaska

-11-

Arizona
County

Employee- Dependent,
Only
Family, etc.

Apache

8,205

23,802

Cochise

7,758

21,771

Coconino

8,205

23,802

Gila

7,732

20,592

Graham

7,758

21,771

Greenlee

7,758

21,771

La Paz

8,893

24,548

Maricopa

7,176

22,558

Mohave

8,205

23,802

Navajo

8,205

23,802

Pima

7,513

21,227

Pinal

7,732

20,592

Santa Cruz

7,513

21,227

Yavapai

7,412

21,670

Yuma

8,893

24,548

Arkansas
County

Employee- Dependent,
Only
Family, etc.

Arkansas

7,140

17,389

Ashley

7,140

17,389

Baxter

7,244

21,429

Benton

7,244

21,429

Boone

7,244

21,429

Bradley

7,140

17,389

Calhoun

7,695

23,029

Carroll

7,244

21,429

Chicot

7,140

17,389

Clark

6,191

18,872

Clay

7,751

21,560

Cleburne

7,028

19,164

Cleveland

7,140

17,389

Columbia

7,695

23,029

Conway

7,028

19,164

Craighead

7,751

21,560

Stone

7,751

21,560

Santa Clara

9,709

28,911

Crawford

6,714

21,788

Union

7,695

23,029

Santa Cruz

9,395

26,386

Crittenden

7,751

21,560

Van Buren

7,028

19,164

Shasta

9,825

23,668

Cross

7,751

21,560

Washington

7,244

21,429

Sierra

9,825

23,668

Dallas

7,140

17,389

White

7,028

19,164

Siskiyou

9,825

23,668

Desha

7,140

17,389

Woodruff

7,751

21,560

Solano

8,407

22,859

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Drew

7,140

17,389

Faulkner

7,028

19,164

Franklin

6,714

21,788

Fulton

7,751

21,560

Garland

6,191

18,872

County

Grant

7,028

19,164

Yell

7,028

19,164

Sonoma

8,407

22,859

Stanislaus

9,008

24,693

Sutter

9,825

23,668

Employee- Dependent,
Only
Family, etc.

Tehama

9,825

23,668

Trinity

9,825

23,668

Alameda

9,991

26,876

Tulare

9,008

24,693

9,825

23,668

California

Greene

7,751

21,560

Alpine

Tuolumne

9,825

23,668

Hempstead

7,695

23,029

Amador

9,825

23,668

Ventura

8,551

25,169

Hot Spring

6,191

18,872

Butte

9,825

23,668

Yolo

8,099

24,093

9,825

23,668

Yuba

9,825

23,668

Howard

7,695

23,029

Calaveras

Independence

7,751

21,560

Colusa

9,825

23,668

Izard

7,751

21,560

Contra Costa

9,461

26,914

Jackson

7,751

21,560

Del Norte

9,825

23,668

Jefferson

7,140

17,389

El Dorado

8,099

24,093

County

Employee- Dependent,
Only
Family, etc.

Johnson

6,714

21,788

Fresno

8,250

25,788

Adams

7,411

21,656

9,825

23,668

Alamosa

8,633

23,653

Colorado

Lafayette

7,695

23,029

Glenn

Lawrence

7,751

21,560

Humboldt

9,825

23,668

Arapahoe

7,411

21,656

17,389

Imperial

8,038

22,422

Archuleta

8,143

24,827

8,038

22,422

Baca

8,633

23,653

Lee

7,140

Lincoln

7,140

17,389

Inyo

Little River

7,695

23,029

Kern

8,576

20,242

Bent

8,633

23,653

21,788

Kings

8,250

25,788

Boulder

7,775

22,089

9,825

23,668

Broomfield

7,411

21,656

Logan

6,714

Lonoke

7,028

19,164

Lake

Madison

7,244

21,429

Lassen

9,825

23,668

Chaffee

8,633

23,653

21,429

Los Angeles

8,516

24,150

Cheyenne

8,633

23,653

8,250

25,788

Clear Creek

7,411

21,656

Marion

7,244

Miller

7,695

23,029

Madera

Mississippi

7,751

21,560

Marin

8,407

22,859

Conejos

8,633

23,653

17,389

Mariposa

9,008

24,693

Costilla

8,633

23,653

9,825

23,668

Crowley

8,633

23,653

Monroe

7,140

Montgomery

6,191

18,872

Mendocino

Nevada

7,695

23,029

Merced

9,008

24,693

Custer

8,633

23,653

9,825

23,668

Delta

8,143

24,827

Newton

7,244

21,429

Modoc

Ouachita

7,695

23,029

Mono

8,038

22,422

Denver

7,411

21,656

Perry

7,028

19,164

Monterey

9,395

26,386

Dolores

8,143

24,827

8,407

22,859

Douglas

7,411

21,656

Phillips

7,140

17,389

Napa

Pike

6,191

18,872

Nevada

9,825

23,668

Eagle

7,932

24,678

Poinsett

7,751

21,560

Orange

9,098

26,021

El Paso

6,583

22,503

8,099

24,093

Elbert

7,411

21,656

Polk

6,714

21,788

Placer

Pope

7,028

19,164

Plumas

9,825

23,668

Fremont

8,633

23,653

19,164

Riverside

8,823

24,188

Garfield

7,932

24,678

8,099

24,093

Gilpin

7,411

21,656

Prairie

7,028

Pulaski

7,028

19,164

Sacramento

Randolph

7,751

21,560

San Benito

9,395

26,386

Grand

8,143

24,827

19,164

San Bernardino

8,823

24,188

Gunnison

8,143

24,827

7,936

19,698

Hinsdale

8,143

24,827

Saline

7,028

Scott

6,714

21,788

San Diego

Searcy

7,244

21,429

San Francisco

9,194

32,092

Huerfano

8,633

23,653

21,788

San Joaquin

9,008

24,693

Jackson

8,143

24,827

8,551

25,169

Jefferson

7,411

21,656

Sebastian

6,714

Sevier

7,695

23,029

San Luis Obispo

Sharp

7,751

21,560

San Mateo

10,893

30,804

Kiowa

8,633

23,653

21,560

Santa Barbara

8,551

25,169

Kit Carson

8,633

23,653

St. Francis

7,751

-12-

2023 Average Premium Tables

Florida

La Plata

8,143

24,827

Lake

8,143

24,827

Larimer

8,694

19,824

County

Las Animas

8,633

23,653

Lincoln

8,633

Logan

8,054

Pasco

7,525

22,543

Employee- Dependent,
Only
Family, etc.

Pinellas

7,371

22,139

Polk

8,801

22,081

Alachua

8,574

22,734

Putnam

7,836

23,177

23,653

Baker

7,715

22,501

Santa Rosa

7,489

20,819

23,081

Bay

7,461

21,468

Sarasota

7,521

21,644

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Mesa

8,998

21,727

Bradford

7,686

23,023

Seminole

7,715

20,590

Mineral

8,633

23,653

Brevard

8,879

23,208

St. Johns

10,257

27,879

Moffat

8,143

24,827

Broward

7,925

23,328

St. Lucie

7,591

21,601

7,789

22,571

Montezuma

8,143

24,827

Calhoun

Sumter

7,862

24,206

Montrose

8,143

24,827

Charlotte

8,533

25,787

Suwannee

7,668

22,810

Morgan

8,054

23,081

Citrus

7,757

21,534

Taylor

8,601

24,552

7,626

22,922

Otero

8,633

23,653

Clay

Union

7,932

23,505

Ouray

8,143

24,827

Collier

7,988

29,682

Volusia

8,323

20,111

Park

7,411

21,656

Columbia

8,265

24,544

Wakulla

7,548

23,347

7,735

23,403

Walton

7,767

21,234

Washington

7,947

23,329

Phillips

8,054

23,081

DeSoto

Pitkin

7,932

24,678

Dixie

7,911

21,209

Prowers

8,633

23,653

Duval

7,679

22,097

Pueblo

7,319

20,347

Escambia

7,892

21,756

Rio Blanco

8,143

24,827

Flagler

8,808

22,670

Rio Grande

8,633

23,653

Franklin

8,034

23,949

County

Employee- Dependent,
Only
Family, etc.

Routt

8,143

24,827

Gadsden

7,735

23,387

Appling

10,583

27,444

Saguache

8,633

23,653

Gilchrist

7,658

22,553

Atkinson

7,649

22,962

24,827

Glades

8,083

25,093

Bacon

7,887

23,290

8,463

25,176

San Juan

8,143

Georgia

San Miguel

8,143

24,827

Gulf

8,395

23,946

Baker

Sedgwick

8,054

23,081

Hamilton

7,602

22,503

Baldwin

8,673

24,458

24,678

Hardee

7,526

20,987

Banks

8,299

22,594

9,031

21,237

Summit

7,932

Teller

6,583

22,503

Hendry

8,388

24,714

Barrow

Washington

8,054

23,081

Hernando

8,890

23,493

Bartow

7,850

22,689

26,016

Highlands

8,138

25,498

Ben Hill

8,599

24,744

8,599

24,744

Weld
Yuma

8,306
8,054

23,081

Connecticut

Hillsborough

7,740

25,008

Berrien

Holmes

7,742

22,612

Bibb

8,545

20,662

Indian River

7,568

21,289

Bleckley

8,545

20,662

7,887

23,290

Jackson

7,381

20,719

Brantley

Jefferson

8,243

22,557

Brooks

8,599

24,744

10,583

27,444

County

Employee- Dependent,
Only
Family, etc.

Fairfield

9,528

29,578

Lafayette

7,903

21,405

Bryan

Hartford

9,002

26,680

Lake

9,585

24,889

Bulloch

10,583

27,444

Litchfield

8,527

28,343

Lee

7,667

22,838

Burke

8,071

20,462

Middlesex

8,672

27,077

Leon

9,230

28,653

Butts

7,850

22,689

New Haven

9,794

29,443

Levy

7,541

23,288

Calhoun

8,463

25,176

New London

8,729

25,787

Liberty

7,894

22,899

Camden

7,887

23,290

Tolland

8,001

22,920

Madison

8,248

23,532

Candler

10,583

27,444

Windham

8,489

31,760

Manatee

7,718

21,046

Carroll

8,130

24,070

Marion

6,342

20,829

Catoosa

7,913

23,868

7,887

23,290

Delaware
County

Employee- Dependent,
Only
Family, etc.

All

8,846

23,764

District of Columbia
County

Employee- Dependent,
Only
Family, etc.

All

9,368

28,176

2023 Average Premium Tables

Martin

8,016

24,627

Charlton

Miami-Dade

8,031

24,816

Chatham

10,583

27,444

Monroe

8,436

25,476

Chattahoochee

7,316

20,658

8,654

22,433

Nassau

8,332

20,919

Chattooga

Okaloosa

8,059

28,477

Cherokee

7,850

22,689

Okeechobee

8,465

24,963

Clarke

9,031

21,237

8,463

25,176

Orange

7,953

20,908

Clay

Osceola

8,438

24,353

Clayton

7,850

22,689

Palm Beach

8,603

28,912

Clinch

8,599

24,744

-13-

Cobb

7,850

22,689

Lanier

8,599

24,744

Towns

8,299

22,594

Coffee

7,649

22,962

Laurens

7,649

22,962

Treutlen

7,649

22,962

Colquitt

8,599

24,744

Lee

8,463

25,176

Troup

7,316

20,658

Columbia

8,071

20,462

Liberty

10,583

27,444

Turner

8,599

24,744

Cook

8,599

24,744

Lincoln

8,071

20,462

Twiggs

8,545

20,662

Coweta

7,850

22,689

Long

10,583

27,444

Union

8,299

22,594

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Crawford

8,545

20,662

Lowndes

8,599

24,744

Upson

7,316

20,658

Crisp

8,463

25,176

Lumpkin

8,299

22,594

Walker

7,913

23,868

Dade

7,913

23,868

Macon

7,316

20,658

Walton

7,850

22,689

Dawson

8,299

22,594

Madison

9,031

21,237

Ware

7,887

23,290

Decatur

8,599

24,744

Marion

7,316

20,658

Warren

8,071

20,462

DeKalb

7,850

22,689

McDuffie

8,071

20,462

Washington

8,673

24,458

Dodge

8,545

20,662

McIntosh

7,887

23,290

Wayne

7,887

23,290

Dooly

8,545

20,662

Meriwether

7,316

20,658

Webster

7,316

20,658

Dougherty

8,463

25,176

Miller

8,599

24,744

Wheeler

7,649

22,962

Douglas

7,850

22,689

Mitchell

8,463

25,176

White

8,299

22,594

Early

8,599

24,744

Monroe

8,545

20,662

Whitfield

8,050

23,245

Echols

8,599

24,744

Montgomery

7,649

22,962

Wilcox

8,545

20,662

Effingham

10,583

27,444

Morgan

9,031

21,237

Wilkes

8,071

20,462

Elbert

9,031

21,237

Murray

8,050

23,245

Wilkinson

8,673

24,458

Emanuel

8,071

20,462

Muscogee

7,316

20,658

Worth

8,463

25,176

Evans

10,583

27,444

Newton

7,850

22,689

Fannin

8,050

23,245

Oconee

9,031

21,237

Fayette

7,850

22,689

Oglethorpe

9,031

21,237

Floyd

8,654

22,433

Paulding

7,850

22,689

County

Employee- Dependent,
Only
Family, etc.

Forsyth

7,850

22,689

Peach

8,545

20,662

All

8,011

Franklin

8,299

22,594

Pickens

8,654

22,433

Fulton

7,850

22,689

Pierce

7,887

23,290

Gilmer

8,654

22,433

Pike

7,850

22,689

Glascock

8,071

20,462

Polk

8,654

22,433

Glynn

7,887

23,290

Pulaski

8,545

20,662

Gordon

8,654

22,433

Putnam

8,545

20,662

Grady

8,599

24,744

Quitman

7,316

20,658

Greene

9,031

21,237

Rabun

8,299

22,594

Gwinnett

7,850

22,689

Randolph

8,463

25,176

Habersham

8,299

22,594

Richmond

8,071

20,462

Hall

8,299

22,594

Rockdale

7,850

22,689

Hancock

8,673

24,458

Schley

8,463

25,176

Haralson

8,130

24,070

Screven

10,583

27,444

Harris

7,316

20,658

Seminole

8,599

24,744

Hart

8,299

22,594

Spalding

7,850

22,689

Heard

8,130

24,070

Stephens

8,299

22,594

Henry

7,850

22,689

Stewart

7,316

20,658

Houston

8,545

20,662

Sumter

8,463

25,176

Irwin

8,599

24,744

Talbot

7,316

20,658

Jackson

9,031

21,237

Taliaferro

8,071

20,462

Jasper

7,850

22,689

Tattnall

10,583

27,444

Jeff Davis

7,649

22,962

Taylor

7,316

20,658

Jefferson

8,071

20,462

Telfair

7,649

22,962

Jenkins

8,071

20,462

Terrell

8,463

25,176

Johnson

7,649

22,962

Thomas

8,599

24,744

Jones

8,545

20,662

Tift

8,599

24,744

Lamar

7,850

22,689

Toombs

7,649

22,962

-14-

Hawaii

21,523

Idaho

County

Employee- Dependent,
Only
Family, etc.

Ada

7,011

18,558

Adams

6,888

18,579

Bannock

8,437

18,200

Bear Lake

8,437

18,200

Benewah

7,005

16,122

Bingham

8,437

18,200

Blaine

6,476

18,948

Boise

6,888

18,579

Bonner

7,005

16,122

Bonneville

7,918

20,506

Boundary

7,005

16,122

Butte

8,437

18,200

Camas

6,476

18,948

Canyon

6,888

18,579

Caribou

8,437

18,200

Cassia

6,476

18,948

Clark

7,918

20,506

Clearwater

8,172

19,086

Custer

8,437

18,200

Elmore

6,888

18,579

Franklin

8,437

18,200

Fremont

7,918

20,506

Gem

6,888

18,579

2023 Average Premium Tables

Gooding

6,476

18,948

Fulton

8,720

23,057

Saline

9,777

25,949

Idaho

8,172

19,086

Gallatin

9,777

25,949

Sangamon

8,465

20,916

Jefferson

7,918

20,506

Greene

8,687

25,047

Schuyler

8,465

20,916

Jerome

6,476

18,948

Grundy

9,101

20,715

Scott

8,465

20,916

Kootenai

7,005

16,122

Hamilton

9,777

25,949

Shelby

8,465

20,916

Latah

7,005

16,122

Hancock

8,243

22,350

St. Clair

8,482

22,961

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Lemhi

7,918

20,506

Hardin

9,777

25,949

Stark

8,720

23,057

Lewis

8,172

19,086

Henderson

8,243

22,350

Stephenson

8,972

22,362

Lincoln

6,476

18,948

Henry

8,243

22,350

Tazewell

8,720

23,057

Madison

7,918

20,506

Iroquois

9,646

23,421

Union

9,777

25,949

Minidoka

6,476

18,948

Jackson

9,777

25,949

Vermilion

9,646

23,421

Nez Perce

8,172

19,086

Jasper

9,777

25,949

Wabash

9,777

25,949

Oneida

8,437

18,200

Jefferson

9,777

25,949

Warren

8,243

22,350

Owyhee

6,888

18,579

Jersey

8,687

25,047

Washington

8,687

25,047

Payette

6,888

18,579

Jo Daviess

8,972

22,362

Wayne

9,777

25,949

Power

8,437

18,200

Johnson

9,777

25,949

White

9,777

25,949

Shoshone

7,005

16,122

Kane

8,977

24,388

Whiteside

8,243

22,350

Teton

7,918

20,506

Kankakee

9,101

20,715

Will

9,101

20,715

Twin Falls

6,476

18,948

Kendall

9,101

20,715

Williamson

9,777

25,949

Valley

6,888

18,579

Knox

8,720

23,057

Winnebago

8,972

22,362

Washington

6,888

18,579

Lake

8,491

24,199

Woodford

8,720

23,057

LaSalle

8,720

23,057

Lawrence

9,777

25,949

Illinois

Indiana

Employee- Dependent,
Only
Family, etc.

Lee

8,972

22,362

County

Livingston

9,902

24,851

County

Employee- Dependent,
Only
Family, etc.

Adams

8,465

20,916

Logan

8,465

20,916

Adams

7,571

23,214

Alexander

9,777

25,949

20,916

Allen

8,107

24,189

Bond

8,687

25,047

Macoupin

8,687

25,047

Bartholomew

7,972

22,956

Boone

8,972

22,362

Madison

8,482

22,961

Benton

8,516

25,391

Brown

8,465

20,916

25,949

Blackford

8,548

23,755

Bureau

8,243

22,350

Marshall

8,720

23,057

Boone

8,202

25,255

Calhoun

8,687

25,047

Mason

8,465

20,916

Brown

8,081

26,469

Carroll

8,972

22,362

25,949

Carroll

8,352

26,016

8,166

21,331

Macon

Marion

Massac

8,465

9,777

9,777

Cass

8,465

20,916

McDonough

8,720

23,057

Cass

Champaign

9,646

23,421

McHenry

8,491

24,199

Clark

7,522

21,619

Christian

8,465

20,916

McLean

9,902

24,851

Clay

7,770

23,405

Clark

9,646

23,421

Menard

8,465

20,916

Clinton

8,352

26,016

Clay

9,777

25,949

Mercer

8,243

22,350

Crawford

7,522

21,619

Clinton

8,687

25,047

Monroe

8,482

22,961

Daviess

8,249

25,780

Coles

9,646

23,421

Montgomery

8,687

25,047

Dearborn

8,906

24,245

Cook

8,729

23,937

Morgan

8,465

20,916

Decatur

7,972

22,956

Crawford

9,777

25,949

Moultrie

8,465

20,916

DeKalb

7,571

23,214

Cumberland

9,646

23,421

Ogle

8,972

22,362

Delaware

8,548

23,755

DeKalb

8,972

22,362

23,057

Dubois

8,249

25,780

DeWitt

9,902

24,851

Perry

9,777

25,949

Elkhart

8,340

22,494

Douglas

9,646

23,421

Piatt

9,646

23,421

Fayette

8,158

24,148

DuPage

8,977

24,388

20,916

Floyd

7,522

21,619

Edgar

9,646

23,421

Pope

9,777

25,949

Fountain

8,352

26,016

Edwards

9,777

25,949

Pulaski

9,777

25,949

Franklin

8,906

24,245

Effingham

9,777

25,949

23,057

Fulton

8,166

21,331

9,588

24,463

Peoria

Pike

Putnam

8,720

8,465

8,720

Fayette

9,777

25,949

Randolph

8,687

25,047

Gibson

Ford

9,646

23,421

Richland

9,777

25,949

Grant

8,548

23,755

Franklin

9,777

25,949

22,350

Greene

8,249

25,780

2023 Average Premium Tables

Rock Island

8,243

-15-

Hamilton

8,202

25,255

Vanderburgh

9,588

24,463

Guthrie

8,697

21,249

Hancock

8,158

24,148

Vermillion

7,770

23,405

Hamilton

6,970

20,188

Harrison

7,522

21,619

Vigo

7,770

23,405

Hancock

7,445

21,955

Hendricks

8,202

25,255

Wabash

7,571

23,214

Hardin

6,970

20,188

Henry

8,158

24,148

Warren

8,516

25,391

Harrison

8,697

21,249

Howard

8,166

21,331

Warrick

9,588

24,463

Henry

7,311

19,465

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Huntington

7,571

23,214

Washington

7,522

21,619

Howard

7,445

21,955

Jackson

7,972

22,956

Wayne

8,158

24,148

Humboldt

7,445

21,955

Jasper

8,516

25,391

Wells

7,571

23,214

Ida

8,032

22,897

Jay

8,548

23,755

White

8,516

25,391

Iowa

7,270

21,569

Jefferson

7,522

21,619

Whitley

7,571

23,214

Jackson

7,270

21,569

Jennings

7,972

22,956

Jasper

7,095

22,233

Johnson

8,081

26,469

Jefferson

7,311

19,465

Knox

8,249

25,780

7,270

21,569

Kosciusko

8,340

22,494

County

Employee- Dependent,
Only
Family, etc.

Johnson
Jones

7,270

21,569

8,697

21,249

Iowa

LaGrange

7,571

23,214

Adair

Keokuk

7,311

19,465

Lake

8,474

22,352

Adams

8,697

21,249

Kossuth

7,445

21,955

LaPorte

8,474

22,352

Allamakee

7,445

21,955

Lee

7,311

19,465

7,311

19,465

Lawrence

8,081

26,469

Appanoose

Linn

7,270

21,569

Madison

8,158

24,148

Audubon

8,697

21,249

Louisa

7,311

19,465

Marion

8,202

25,255

Benton

7,270

21,569

Lucas

7,311

19,465

7,270

21,569

Marshall

8,340

22,494

Black Hawk

Lyon

8,032

22,897

Martin

8,249

25,780

Boone

6,970

20,188

Madison

7,095

22,233

7,445

21,955

Miami

8,166

21,331

Bremer

Mahaska

7,311

19,465

Monroe

8,081

26,469

Buchanan

7,270

21,569

Marion

7,095

22,233

Montgomery

8,352

26,016

Buena Vista

8,032

22,897

Marshall

6,970

20,188

7,445

21,955

Morgan

8,202

25,255

Butler

Mills

8,697

21,249

Newton

8,516

25,391

Calhoun

6,970

20,188

Mitchell

7,445

21,955

Noble

7,571

23,214

Carroll

6,970

20,188

Monona

8,032

22,897

8,697

21,249

Ohio

8,906

24,245

Cass

Monroe

7,311

19,465

Orange

8,249

25,780

Cedar

7,270

21,569

Montgomery

8,697

21,249

Owen

8,081

26,469

Cerro Gordo

7,445

21,955

Muscatine

7,311

19,465

8,032

22,897

Parke

7,770

23,405

Cherokee

O'Brien

8,032

22,897

Perry

8,249

25,780

Chickasaw

7,445

21,955

Osceola

8,032

22,897

Pike

8,249

25,780

Clarke

8,697

21,249

Page

8,697

21,249

8,032

22,897

Porter

8,474

22,352

Clay

Palo Alto

8,032

22,897

Posey

9,588

24,463

Clayton

7,270

21,569

Plymouth

8,032

22,897

Pulaski

8,166

21,331

Clinton

7,270

21,569

Pocahontas

8,032

22,897

8,032

22,897

Putnam

8,352

26,016

Crawford

Polk

7,095

22,233

Randolph

8,548

23,755

Dallas

7,095

22,233

Pottawattamie

8,697

21,249

Ripley

8,906

24,245

Davis

7,311

19,465

Poweshiek

6,970

20,188

8,697

21,249

Rush

7,972

22,956

Decatur

Ringgold

8,697

21,249

Scott

7,522

21,619

Delaware

7,270

21,569

Sac

8,032

22,897

7,311

19,465

Shelby

8,202

25,255

Des Moines

Scott

7,270

21,569

Spencer

8,249

25,780

Dickinson

8,032

22,897

Shelby

8,697

21,249

St. Joseph

8,340

22,494

Dubuque

7,270

21,569

Sioux

8,032

22,897

7,445

21,955

Starke

8,340

22,494

Emmet

Story

6,970

20,188

Steuben

7,571

23,214

Fayette

7,445

21,955

Tama

6,970

20,188

Sullivan

7,770

23,405

Floyd

7,445

21,955

Taylor

8,697

21,249

7,445

21,955

Switzerland

8,906

24,245

Franklin

Union

8,697

21,249

Tippecanoe

8,352

26,016

Fremont

8,697

21,249

Van Buren

7,311

19,465

Tipton

8,352

26,016

Greene

6,970

20,188

Wapello

7,311

19,465

24,148

Grundy

6,970

20,188

Warren

7,095

22,233

Union

8,158

-16-

2023 Average Premium Tables

Washington

7,311

19,465

Hodgeman

6,640

20,210

Stevens

6,640

20,210

Wayne

7,311

19,465

Jackson

7,004

19,947

Sumner

6,660

18,161

Webster

6,970

20,188

Jefferson

7,004

19,947

Thomas

7,246

21,412

Winnebago

7,445

21,955

Jewell

6,556

17,604

Trego

7,246

21,412

Winneshiek

7,445

21,955

Johnson

7,490

20,490

Wabaunsee

7,004

19,947

Woodbury

8,032

22,897

Kearny

6,640

20,210

Wallace

7,246

21,412

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Worth

7,445

21,955

Kingman

6,660

18,161

Washington

6,556

17,604

Wright

7,445

21,955

Kiowa

6,640

20,210

Wichita

7,246

21,412

Labette

7,646

19,378

Wilson

6,660

18,161

Lane

7,246

21,412

Woodson

7,646

19,378

7,490

20,490

Wyandotte

7,490

20,490

Kansas
County

Employee- Dependent,
Only
Family, etc.

Leavenworth
Lincoln

6,556

17,604

Allen

7,646

19,378

Linn

7,004

19,947

Anderson

7,004

19,947

Logan

7,246

21,412

Atchison

7,004

19,947

Lyon

7,004

19,947

County

Employee- Dependent,
Only
Family, etc.

Barber

6,640

20,210

Marion

6,660

18,161

Adair

7,995

23,900

7,995

23,900

Kentucky

Barton

7,246

21,412

Marshall

7,004

19,947

Allen

Bourbon

7,646

19,378

McPherson

6,660

18,161

Anderson

6,923

19,939

Brown

7,004

19,947

Meade

6,640

20,210

Ballard

9,237

20,839

Butler

6,660

18,161

Miami

7,490

20,490

Barren

7,995

23,900

Chase

6,660

18,161

Mitchell

6,556

17,604

Bath

7,608

22,247

Chautauqua

6,660

18,161

Montgomery

6,660

18,161

Bell

8,511

23,588

Cherokee

7,646

19,378

Morris

6,556

17,604

Boone

6,901

20,870

Cheyenne

7,246

21,412

20,210

Bourbon

6,923

19,939

Clark

6,640

20,210

Nemaha

7,004

19,947

Boyd

7,608

22,247

Clay

6,556

17,604

Neosho

7,646

19,378

Boyle

6,923

19,939

Cloud

6,556

17,604

21,412

Bracken

7,608

22,247

Coffey

7,004

19,947

Norton

7,246

21,412

Breathitt

8,511

23,588

Comanche

6,640

20,210

Osage

7,004

19,947

Breckinridge

7,219

20,556

Cowley

6,660

18,161

21,412

Bullitt

7,219

20,556

Crawford

7,646

19,378

Ottawa

6,556

17,604

Butler

7,995

23,900

Decatur

7,246

21,412

Pawnee

6,640

20,210

Caldwell

9,237

20,839

Dickinson

6,556

17,604

21,412

Calloway

9,237

20,839

6,901

20,870

Morton

Ness

Osborne

Phillips

6,640

7,246

7,246

7,246

Doniphan

7,004

19,947

Pottawatomie

7,004

19,947

Campbell

Douglas

7,004

19,947

Pratt

6,640

20,210

Carlisle

9,237

20,839

Edwards

6,640

20,210

Rawlins

7,246

21,412

Carroll

7,219

20,556

Elk

6,660

18,161

Reno

6,660

18,161

Carter

7,608

22,247

Ellis

7,246

21,412

Republic

6,556

17,604

Casey

7,995

23,900

Ellsworth

6,556

17,604

Rice

6,660

18,161

Christian

8,681

23,593

Finney

6,640

20,210

Riley

6,556

17,604

Clark

6,923

19,939

Ford

6,640

20,210

Rooks

7,246

21,412

Clay

8,511

23,588

Franklin

7,004

19,947

Rush

7,246

21,412

Clinton

7,995

23,900

Geary

6,556

17,604

Russell

7,246

21,412

Crittenden

9,237

20,839

Gove

7,246

21,412

17,604

Cumberland

7,995

23,900

Graham

7,246

21,412

Scott

7,246

21,412

Daviess

8,681

23,593

Grant

6,640

20,210

Sedgwick

6,660

18,161

Edmonson

7,995

23,900

Gray

6,640

20,210

20,210

Elliott

7,608

22,247

Greeley

7,246

21,412

Shawnee

7,004

19,947

Estill

6,923

19,939

Greenwood

6,660

18,161

Sheridan

7,246

21,412

Fayette

6,923

19,939

Hamilton

6,640

20,210

21,412

Fleming

7,608

22,247

8,511

23,588

Saline

Seward

Sherman

6,556

6,640

7,246

Harper

6,660

18,161

Smith

7,246

21,412

Floyd

Harvey

6,660

18,161

Stafford

6,640

20,210

Franklin

6,923

19,939

Haskell

6,640

20,210

20,210

Fulton

9,237

20,839

2023 Average Premium Tables

Stanton

6,640

-17-

Gallatin

6,901

20,870

Ohio

8,681

23,593

Franklin

8,275

20,521

Garrard

6,923

19,939

Oldham

7,219

20,556

Grant

8,797

22,437

Grant

6,901

20,870

Owen

6,923

19,939

Iberia

7,541

20,453

Graves

9,237

20,839

Owsley

8,511

23,588

Iberville

8,072

21,892

Grayson

7,219

20,556

Pendleton

6,901

20,870

Jackson

8,275

20,521

Green

7,995

23,900

Perry

8,511

23,588

Jefferson

7,665

21,666

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Greenup

7,608

22,247

Pike

8,511

23,588

Jefferson Davis

8,459

21,861

Hancock

8,681

23,593

Powell

6,923

19,939

Lafayette

7,541

20,453

Hardin

7,219

20,556

Pulaski

7,995

23,900

Lafourche

7,692

20,542

Harlan

8,511

23,588

Robertson

7,608

22,247

LaSalle

8,797

22,437

Harrison

6,923

19,939

Rockcastle

6,923

19,939

Lincoln

8,275

20,521

Hart

7,995

23,900

Rowan

7,608

22,247

Livingston

8,072

21,892

Henderson

8,681

23,593

Russell

7,995

23,900

Madison

8,275

20,521

Henry

7,219

20,556

Scott

6,923

19,939

Morehouse

8,275

20,521

Hickman

9,237

20,839

Shelby

7,219

20,556

Natchitoches

7,834

21,179

Hopkins

8,681

23,593

Simpson

7,995

23,900

Orleans

7,665

21,666

Jackson

6,923

19,939

Spencer

7,219

20,556

Ouachita

8,275

20,521

Jefferson

7,219

20,556

Taylor

7,995

23,900

Plaquemines

7,665

21,666

Jessamine

6,923

19,939

Todd

8,681

23,593

Pointe Coupee

8,072

21,892

Johnson

8,511

23,588

Trigg

8,681

23,593

Rapides

8,797

22,437

Kenton

6,901

20,870

Trimble

7,219

20,556

Red River

7,834

21,179

Knott

8,511

23,588

Union

8,681

23,593

Richland

8,275

20,521

Knox

8,511

23,588

Warren

7,995

23,900

Sabine

7,834

21,179

LaRue

7,219

20,556

Washington

7,219

20,556

St. Bernard

7,665

21,666

Laurel

8,511

23,588

Wayne

7,995

23,900

St. Charles

7,665

21,666

Lawrence

7,608

22,247

Webster

8,681

23,593

St. Helena

8,072

21,892

Lee

8,511

23,588

Whitley

8,511

23,588

St. James

7,665

21,666

Leslie

8,511

23,588

Wolfe

8,511

23,588

St. John Baptist

7,665

21,666

Letcher

8,511

23,588

Woodford

6,923

19,939

St. Landry

7,541

20,453

Lewis

7,608

22,247

St. Martin

7,541

20,453

Lincoln

6,923

19,939

St. Mary

7,541

20,453

Livingston

9,237

20,839

7,665

21,666

Louisiana
Employee- Dependent,
Only
Family, etc.

St. Tammany

Logan

7,995

23,900

Parish

Tangipahoa

8,072

21,892

Lyon

9,237

20,839

Acadia

7,541

20,453

Tensas

8,275

20,521

Madison

6,923

19,939

Allen

8,459

21,861

Terrebonne

7,692

20,542

8,072

21,892

Magoffin

8,511

23,588

Ascension

Union

8,275

20,521

Marion

7,219

20,556

Assumption

7,692

20,542

Vermilion

7,541

20,453

Marshall

9,237

20,839

Avoyelles

8,797

22,437

Vernon

8,797

22,437

8,459

21,861

Martin

8,511

23,588

Beauregard

Washington

8,072

21,892

Mason

7,608

22,247

Bienville

7,834

21,179

Webster

7,834

21,179

McCracken

9,237

20,839

Bossier

7,834

21,179

West Baton Rouge

8,072

21,892

7,834

21,179

McCreary

7,995

23,900

Caddo

West Carroll

8,275

20,521

McLean

8,681

23,593

Calcasieu

8,459

21,861

West Feliciana

8,072

21,892

8,275

20,521

Winn

8,797

22,437

Meade

7,219

20,556

Caldwell

Menifee

7,608

22,247

Cameron

8,459

21,861

Mercer

6,923

19,939

Catahoula

8,797

22,437

Metcalfe

7,995

23,900

Claiborne

7,834

21,179

8,797

22,437

County

Employee- Dependent,
Only
Family, etc.

Maine

Monroe

7,995

23,900

Concordia

Montgomery

6,923

19,939

DeSoto

7,834

21,179

Androscoggin

8,045

22,601

22,247

East Baton Rouge

8,072

21,892

Aroostook

9,703

24,940

8,275

20,521

Cumberland

7,735

22,574

Morgan

7,608

Muhlenberg

8,681

23,593

East Carroll

Nelson

7,219

20,556

East Feliciana

8,072

21,892

Franklin

8,045

22,601

19,939

Evangeline

7,541

20,453

Hancock

9,703

24,940

Nicholas

6,923

-18-

2023 Average Premium Tables

Kennebec

7,517

20,158

Norfolk

9,358

26,811

Lenawee

7,587

22,510

Knox

7,517

20,158

Plymouth

9,361

25,875

Livingston

7,587

22,510

Lincoln

7,517

20,158

Suffolk

9,358

26,811

Luce

9,363

22,114

Oxford

7,517

20,158

Worcester

8,989

25,350

Mackinac

8,510

22,856

Penobscot

8,045

22,601

Macomb

7,838

22,752

Piscataquis

8,045

22,601

Manistee

7,203

21,345

Michigan

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Sagadahoc

7,735

22,574

9,363

22,114

8,045

22,601

County

Employee- Dependent,
Only
Family, etc.

Marquette

Somerset

Mason

7,097

21,254

Waldo

8,045

22,601

Alcona

8,510

22,856

Mecosta

7,097

21,254

9,363

22,114

Washington

9,703

24,940

Alger

Menominee

9,363

22,114

York

7,735

22,574

Allegan

7,197

21,587

Midland

7,425

21,232

Alpena

8,510

22,856

Missaukee

7,203

21,345

Antrim

7,203

21,345

Monroe

8,584

24,261

Arenac

7,898

20,833

Montcalm

7,097

21,254

Baraga

9,363

22,114

Montmorency

8,510

22,856

Maryland
County

Employee- Dependent,
Only
Family, etc.

Allegany

8,282

24,040

Barry

7,197

21,587

Muskegon

7,097

21,254

Anne Arundel

8,273

22,894

Bay

7,898

20,833

Newaygo

7,097

21,254

Baltimore

8,273

22,894

Benzie

7,203

21,345

Oakland

7,838

22,752

Baltimore City

8,273

22,894

Berrien

8,527

24,805

Oceana

7,097

21,254

Calvert

8,337

21,174

Branch

8,488

22,633

Ogemaw

8,510

22,856

Caroline

8,337

21,174

Calhoun

8,488

22,633

Ontonagon

9,363

22,114

Carroll

8,282

24,040

Cass

8,527

24,805

Osceola

7,097

21,254

Cecil

8,337

21,174

Charlevoix

7,203

21,345

Oscoda

8,510

22,856

Charles

8,337

21,174

Cheboygan

8,510

22,856

Otsego

8,510

22,856

Dorchester

8,337

21,174

Chippewa

8,510

22,856

Ottawa

7,097

21,254

Frederick

8,282

24,040

Clare

7,425

21,232

Presque Isle

8,510

22,856

Garrett

8,282

24,040

Clinton

8,521

21,466

Roscommon

8,510

22,856

Harford

8,273

22,894

Crawford

8,510

22,856

Saginaw

7,898

20,833

Howard

8,273

22,894

Delta

9,363

22,114

Sanilac

8,709

21,559

Kent

8,337

21,174

Dickinson

9,363

22,114

Schoolcraft

9,363

22,114

Montgomery

8,718

25,697

Eaton

8,521

21,466

Shiawassee

8,060

19,416

Prince George’s

8,718

25,697

Emmet

7,203

21,345

St. Clair

7,875

22,787

Queen Anne’s

8,337

21,174

Genesee

8,060

19,416

St. Joseph

8,527

24,805

Somerset

8,337

21,174

Gladwin

7,425

21,232

Tuscola

8,709

21,559

St. Mary’s

8,337

21,174

Gogebic

9,363

22,114

Van Buren

8,527

24,805

Talbot

8,337

21,174

Grand Traverse

7,203

21,345

Washtenaw

7,587

22,510

Washington

8,282

24,040

Gratiot

7,898

20,833

Wayne

8,584

24,261

Wicomico

8,337

21,174

Hillsdale

8,521

21,466

Wexford

7,203

21,345

Worcester

8,337

21,174

Houghton

9,363

22,114

Huron

8,709

21,559

Ingham

8,521

21,466

7,097

21,254

County

Employee- Dependent,
Only
Family, etc.

County

Employee- Dependent,
Only
Family, etc.

Ionia
Iosco

8,510

22,856

Aitkin

8,499

22,222

Barnstable

11,191

27,157

Iron

9,363

22,114

Anoka

8,198

23,928

Berkshire

8,363

24,733

Isabella

7,425

21,232

Becker

8,286

23,575

Bristol

9,361

25,875

Jackson

8,521

21,466

Beltrami

8,499

22,222

Dukes

11,191

27,157

Kalamazoo

8,488

22,633

Benton

8,198

23,928

Essex

9,148

25,727

Kalkaska

7,203

21,345

Big Stone

9,311

21,521

Franklin

8,363

24,733

Kent

7,097

21,254

Blue Earth

10,352

21,766

Hampden

8,363

24,733

Keweenaw

9,363

22,114

Brown

8,725

22,580

Hampshire

8,363

24,733

Lake

7,097

21,254

Carlton

8,693

21,889

Middlesex

9,358

26,811

Lapeer

8,060

19,416

Carver

8,198

23,928

Nantucket

11,191

27,157

Leelanau

7,203

21,345

Cass

8,499

22,222

Massachusetts

2023 Average Premium Tables

-19-

Minnesota

Chippewa

9,311

21,521

Renville

9,311

21,521

Humphreys

6,958

18,688

Chisago

8,499

22,222

Rice

10,352

21,766

Issaquena

6,958

18,688

Clay

8,286

23,575

Rock

8,725

22,580

Itawamba

7,340

18,912

Clearwater

7,342

23,307

Roseau

8,499

22,222

Jackson

7,844

23,137

Cook

8,693

21,889

Scott

8,198

23,928

Jasper

6,958

18,688

Cottonwood

8,725

22,580

Sherburne

8,198

23,928

Jefferson

6,958

18,688

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Crow Wing

8,499

22,222

Sibley

9,311

21,521

Jefferson Davis

6,958

18,688

Dakota

8,198

23,928

St. Louis

8,693

21,889

Jones

7,522

17,322

Dodge

8,999

23,347

Stearns

8,198

23,928

Kemper

6,958

18,688

Douglas

8,286

23,575

Steele

8,999

23,347

Lafayette

6,958

18,688

Faribault

10,352

21,766

Stevens

8,286

23,575

Lamar

7,522

17,322

Fillmore

8,999

23,347

Swift

9,311

21,521

Lauderdale

6,958

18,688

Freeborn

8,999

23,347

Todd

8,499

22,222

Lawrence

6,958

18,688

Goodhue

8,999

23,347

Traverse

8,286

23,575

Leake

6,958

18,688

Grant

8,286

23,575

Wabasha

8,999

23,347

Lee

7,340

18,912

Hennepin

8,198

23,928

Wadena

8,499

22,222

Leflore

6,958

18,688

Houston

8,999

23,347

Waseca

10,352

21,766

Lincoln

6,958

18,688

Hubbard

8,499

22,222

Washington

8,198

23,928

Lowndes

6,958

18,688

Isanti

8,499

22,222

Watonwan

10,352

21,766

Madison

7,262

17,857

Itasca

8,693

21,889

Wilkin

8,286

23,575

Marion

6,958

18,688

Jackson

8,725

22,580

Winona

8,999

23,347

Marshall

6,877

23,091

Kanabec

8,499

22,222

Wright

8,198

23,928

Monroe

6,958

18,688

Kandiyohi

9,311

21,521

Yellow Medicine

9,311

21,521

Montgomery

6,958

18,688

Kittson

7,342

23,307

Neshoba

6,958

18,688

Koochiching

8,693

21,889

Newton

6,958

18,688

Lac qui Parle

9,311

21,521

6,958

18,688

Mississippi

Employee- Dependent,
Only
Family, etc.

Noxubee

Lake

8,693

21,889

County

Oktibbeha

6,958

18,688

Lake of the Woods

8,693

21,889

Adams

6,958

18,688

Panola

6,958

18,688

Le Sueur

10,352

21,766

Alcorn

6,958

18,688

Pearl River

7,522

17,322

6,958

18,688

Lincoln

8,725

22,580

Amite

Perry

7,522

17,322

Lyon

9,311

21,521

Attala

6,958

18,688

Pike

6,958

18,688

Mahnomen

7,342

23,307

Benton

7,340

18,912

Pontotoc

7,340

18,912

6,958

18,688

Marshall

7,342

23,307

Bolivar

Prentiss

6,958

18,688

Martin

10,352

21,766

Calhoun

6,958

18,688

Quitman

6,958

18,688

McLeod

9,311

21,521

Carroll

6,958

18,688

Rankin

7,262

17,857

6,958

18,688

Meeker

9,311

21,521

Chickasaw

Scott

6,958

18,688

Mille Lacs

8,499

22,222

Choctaw

6,958

18,688

Sharkey

6,958

18,688

Morrison

8,499

22,222

Claiborne

6,958

18,688

Simpson

7,262

17,857

6,958

18,688

Mower

8,999

23,347

Clarke

Smith

6,958

18,688

Murray

8,725

22,580

Clay

6,958

18,688

Stone

7,844

23,137

Nicollet

10,352

21,766

Coahoma

6,958

18,688

Sunflower

6,958

18,688

7,262

17,857

Nobles

8,725

22,580

Copiah

Tallahatchie

6,958

18,688

Norman

7,342

23,307

Covington

6,958

18,688

Tate

6,877

23,091

6,877

23,091

Olmsted

8,999

23,347

DeSoto

Tippah

7,340

18,912

Otter Tail

8,286

23,575

Forrest

7,522

17,322

Tishomingo

6,958

18,688

Pennington

7,342

23,307

Franklin

6,958

18,688

Tunica

6,877

23,091

7,844

23,137

Pine

8,499

22,222

George

Union

7,340

18,912

Pipestone

8,725

22,580

Greene

7,522

17,322

Walthall

6,958

18,688

Polk

7,342

23,307

Grenada

6,958

18,688

Warren

7,262

17,857

7,844

23,137

Pope

8,286

23,575

Hancock

Washington

6,958

18,688

Ramsey

8,198

23,928

Harrison

7,844

23,137

Wayne

6,958

18,688

Red Lake

7,342

23,307

Hinds

7,262

17,857

Webster

6,958

18,688

22,580

Holmes

6,958

18,688

Wilkinson

6,958

18,688

Redwood

8,725

-20-

2023 Average Premium Tables

Winston

6,958

18,688

Iron

7,282

18,701

St. Francois

7,712

20,240

Yalobusha

6,958

18,688

Jackson

8,567

22,493

St. Louis

7,712

20,240

Yazoo

6,958

18,688

Jasper

7,152

19,025

St. Louis City

7,712

20,240

Jefferson

7,712

20,240

Ste. Genevieve

7,712

20,240

Johnson

7,494

19,730

Stoddard

8,348

22,895

8,548

20,952

Stone

7,843

21,502

Missouri
County

Employee- Dependent,
Only
Family, etc.

Knox
Laclede

7,843

21,502

Sullivan

8,548

20,952

Adair

8,548

20,952

Lafayette

7,494

19,730

Taney

7,843

21,502

Andrew

10,197

19,609

Lawrence

7,843

21,502

Texas

7,282

18,701

Atchison

10,197

19,609

Lewis

8,548

20,952

Vernon

7,494

19,730

Audrain

8,472

21,174

Lincoln

7,712

20,240

Warren

7,712

20,240

Barry

7,843

21,502

Linn

8,548

20,952

Washington

7,712

20,240

Barton

7,152

19,025

Livingston

10,197

19,609

Wayne

8,348

22,895

Bates

7,494

19,730

Macon

8,548

20,952

Webster

7,843

21,502

Benton

7,494

19,730

Madison

8,348

22,895

Worth

10,197

19,609

Bollinger

8,348

22,895

Maries

8,472

21,174

Wright

7,843

21,502

Boone

8,472

21,174

Marion

8,548

20,952

Buchanan

10,197

19,609

McDonald

7,152

19,025

Butler

8,348

22,895

Mercer

10,197

19,609

Caldwell

10,197

19,609

Miller

8,472

21,174

County

Employee- Dependent,
Only
Family, etc.

Callaway

8,472

21,174

Mississippi

8,348

22,895

Beaverhead

8,693

20,347

Camden

8,472

21,174

Moniteau

8,472

21,174

Big Horn

8,693

20,347

Cape Girardeau

8,348

22,895

Monroe

8,472

21,174

Blaine

8,693

20,347

Carroll

10,197

19,609

21,174

Broadwater

7,606

22,167

Carter

7,282

18,701

Morgan

8,472

21,174

Carbon

8,123

22,023

Cass

8,567

22,493

New Madrid

8,348

22,895

Carter

8,693

20,347

Cedar

7,843

21,502

19,025

Cascade

7,606

22,167

Chariton

8,472

21,174

Nodaway

10,197

19,609

Chouteau

7,606

22,167

Christian

7,843

21,502

Oregon

7,282

18,701

Custer

8,693

20,347

Clark

8,548

20,952

21,174

Daniels

8,693

20,347

Clay

8,567

22,493

Ozark

7,843

21,502

Dawson

8,693

20,347

Clinton

10,197

19,609

Pemiscot

8,348

22,895

Deer Lodge

7,606

22,167

Cole

8,472

21,174

22,895

Fallon

8,693

20,347

8,693

20,347

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Montgomery

Newton

Osage

Perry

8,472

7,152

8,472

8,348

Montana

Cooper

8,472

21,174

Pettis

7,494

19,730

Fergus

Crawford

7,282

18,701

Phelps

7,282

18,701

Flathead

7,863

20,820

Dade

7,843

21,502

Pike

8,548

20,952

Gallatin

7,606

22,167

Dallas

7,843

21,502

Platte

8,567

22,493

Garfield

8,693

20,347

Daviess

10,197

19,609

Polk

7,843

21,502

Glacier

8,693

20,347

DeKalb

10,197

19,609

Pulaski

7,282

18,701

Golden Valley

8,693

20,347

Dent

7,282

18,701

Putnam

8,548

20,952

Granite

8,693

20,347

Douglas

7,843

21,502

Ralls

8,548

20,952

Hill

8,693

20,347

Dunklin

8,348

22,895

Randolph

8,472

21,174

Jefferson

7,606

22,167

Franklin

7,712

20,240

Ray

10,197

19,609

Judith Basin

7,606

22,167

Gasconade

8,472

21,174

18,701

Lake

7,863

20,820

Gentry

10,197

19,609

Ripley

7,282

18,701

Lewis and Clark

7,606

22,167

Greene

7,843

21,502

Saline

7,494

19,730

Liberty

8,693

20,347

Grundy

10,197

19,609

20,952

Lincoln

8,693

20,347

Harrison

10,197

19,609

Scotland

8,548

20,952

Madison

8,693

20,347

Henry

7,494

19,730

Scott

8,348

22,895

McCone

8,693

20,347

Hickory

7,843

21,502

18,701

Meagher

8,693

20,347

8,693

20,347

Reynolds

Schuyler

Shannon

7,282

8,548

7,282

Holt

10,197

19,609

Shelby

8,548

20,952

Mineral

Howard

8,472

21,174

St. Charles

7,712

20,240

Missoula

7,863

20,820

Howell

7,282

18,701

19,730

Musselshell

8,123

22,023

2023 Average Premium Tables

St. Clair

7,494

-21-

Park

8,693

20,347

Dodge

7,859

22,206

Seward

9,036

24,033

Petroleum

8,693

20,347

Douglas

7,859

22,206

Sheridan

9,129

25,388

Phillips

8,693

20,347

Dundy

9,129

25,388

Sherman

8,981

26,077

Pondera

8,693

20,347

Fillmore

9,036

24,033

Sioux

9,129

25,388

Powder River

8,693

20,347

Franklin

8,981

26,077

Stanton

8,981

26,077

Powell

8,693

20,347

Frontier

9,129

25,388

Thayer

9,036

24,033

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Prairie

8,693

20,347

Furnas

8,981

26,077

Thomas

9,129

25,388

Ravalli

8,693

20,347

Gage

9,036

24,033

Thurston

7,859

22,206

Richland

8,693

20,347

Garden

9,129

25,388

Valley

8,981

26,077

Roosevelt

8,693

20,347

Garfield

8,981

26,077

Washington

7,859

22,206

Rosebud

8,693

20,347

Gosper

8,981

26,077

Wayne

8,981

26,077

Sanders

8,693

20,347

Grant

9,129

25,388

Webster

8,981

26,077

Sheridan

8,693

20,347

Greeley

8,981

26,077

Wheeler

8,981

26,077

Silver Bow

7,606

22,167

Hall

8,981

26,077

York

9,036

24,033

Stillwater

8,123

22,023

Hamilton

8,981

26,077

Sweet Grass

8,123

22,023

Harlan

8,981

26,077

Teton

7,606

22,167

Hayes

9,129

25,388

Toole

8,693

20,347

Hitchcock

9,129

25,388

County

Employee- Dependent,
Only
Family, etc.

Treasure

8,693

20,347

Holt

8,981

26,077

Carson City

7,344

19,438

Valley

8,693

20,347

Hooker

9,129

25,388

Churchill

7,741

23,111

Wheatland

8,693

20,347

Howard

8,981

26,077

Clark

7,204

20,646

7,344

19,438

Nevada

Wibaux

8,693

20,347

Jefferson

9,036

24,033

Douglas

Yellowstone

8,123

22,023

Johnson

9,036

24,033

Elko

7,741

23,111

26,077

Esmeralda

7,741

23,111

7,741

23,111

Kearney

Nebraska

8,981

Keith

9,129

25,388

Eureka

Keya Paha

8,981

26,077

Humboldt

7,741

23,111

25,388

Lander

7,741

23,111

7,741

23,111

County

Employee- Dependent,
Only
Family, etc.

Adams

8,981

26,077

Knox

8,981

26,077

Lincoln

Antelope

8,981

26,077

Lancaster

9,036

24,033

Lyon

7,344

19,438

Arthur

9,129

25,388

25,388

Mineral

7,741

23,111

Banner

9,129

25,388

Logan

9,129

25,388

Nye

7,204

20,646

Blaine

8,981

26,077

Loup

8,981

26,077

Pershing

7,741

23,111

Boone

8,981

26,077

26,077

Storey

7,344

19,438

8,331

21,180

7,741

23,111

Kimball

Lincoln

Madison

9,129

9,129

8,981

Box Butte

9,129

25,388

McPherson

9,129

25,388

Washoe

Boyd

8,981

26,077

Merrick

8,981

26,077

White Pine

Brown

9,129

25,388

Morrill

9,129

25,388

Buffalo

8,981

26,077

Nance

8,981

26,077

Burt

7,859

22,206

Nemaha

9,036

24,033

Butler

8,981

26,077

Nuckolls

8,981

26,077

Cass

7,859

22,206

Otoe

9,036

24,033

Cedar

8,981

26,077

Pawnee

9,036

24,033

Chase

9,129

25,388

Perkins

9,129

25,388

Cherry

9,129

25,388

Phelps

8,981

26,077

Cheyenne

9,129

25,388

Pierce

8,981

26,077

Clay

8,981

26,077

Platte

8,981

26,077

Colfax

8,981

26,077

Polk

8,981

26,077

Cuming

8,981

26,077

Red Willow

9,129

25,388

Custer

8,981

26,077

Richardson

9,036

24,033

Dakota

8,981

26,077

Rock

8,981

26,077

Dawes

9,129

25,388

Saline

9,036

24,033

Dawson

8,981

26,077

Sarpy

7,859

22,206

Deuel

9,129

25,388

Saunders

7,859

22,206

Dixon

8,981

26,077

Scotts Bluff

9,129

25,388

-22-

New Hampshire
County

Employee- Dependent,
Only
Family, etc.

All

8,498

26,225

New Jersey
County

Employee- Dependent,
Only
Family, etc.

All

8,090

24,143

New Mexico
County

Employee- Dependent,
Only
Family, etc.

Bernalillo

7,758

21,368

Catron

9,379

29,015

Chaves

9,379

29,015

Cibola

9,379

29,015

2023 Average Premium Tables

Colfax

9,379

29,015

Hamilton

9,203

25,195

Bertie

7,967

22,994

Curry

9,379

29,015

Herkimer

9,203

25,195

Bladen

7,391

23,420

De Baca

9,379

29,015

Jefferson

9,203

25,195

Brunswick

7,906

21,413

Doña Ana

8,107

20,387

Kings

11,243

29,771

Buncombe

8,305

21,752

Eddy

9,379

29,015

Lewis

9,203

25,195

Burke

7,960

21,585

Grant

9,379

29,015

Livingston

8,103

20,885

Cabarrus

7,893

22,733

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Guadalupe

9,379

29,015

Madison

9,203

25,195

Caldwell

7,960

21,585

Harding

9,379

29,015

Monroe

8,103

20,885

Camden

7,967

22,994

Hidalgo

9,379

29,015

Montgomery

8,439

21,463

Carteret

9,047

21,390

Lea

9,379

29,015

Nassau

11,034

28,766

Caswell

7,851

25,284

Lincoln

9,379

29,015

New York

11,243

29,771

Catawba

7,960

21,585

Los Alamos

9,379

29,015

Niagara

8,449

20,437

Chatham

7,851

25,284

Luna

9,379

29,015

Oneida

9,203

25,195

Cherokee

8,305

21,752

McKinley

9,379

29,015

Onondaga

9,203

22,260

Chowan

7,967

22,994

Mora

9,379

29,015

Ontario

8,103

20,885

Clay

8,305

21,752

Otero

9,379

29,015

Orange

10,472

25,016

Cleveland

8,254

22,198

Quay

9,379

29,015

Orleans

8,449

20,437

Columbus

7,906

21,413

Rio Arriba

9,379

29,015

Oswego

9,203

25,195

Craven

9,047

21,390

Roosevelt

9,379

29,015

Otsego

9,203

25,195

Cumberland

7,391

23,420

San Juan

7,985

21,236

Putnam

10,472

25,016

Currituck

7,967

22,994

San Miguel

9,379

29,015

Queens

11,243

29,771

Dare

9,047

21,390

Sandoval

7,758

21,368

Rensselaer

8,439

21,463

Davidson

8,418

23,593

Santa Fe

8,139

24,010

Richmond

11,243

29,771

Davie

8,418

23,593

Sierra

9,379

29,015

Rockland

11,243

29,771

Duplin

7,906

21,413

Socorro

9,379

29,015

Saratoga

8,439

21,463

Durham

7,851

25,284

Taos

9,379

29,015

Schenectady

8,439

21,463

Edgecombe

8,970

27,984

Torrance

7,758

21,368

Schoharie

8,439

21,463

Forsyth

8,418

23,593

Union

9,379

29,015

Schuyler

9,203

22,260

Franklin

7,278

22,091

Valencia

7,758

21,368

Seneca

8,103

20,885

Gaston

8,254

22,198

St. Lawrence

9,203

25,195

Gates

7,967

22,994

Steuben

9,203

22,260

Graham

8,305

21,752

11,034

28,766

Granville

7,403

20,823

New York
County

Employee- Dependent,
Only
Family, etc.

Suffolk
Sullivan

10,472

25,016

Greene

8,970

27,984

Albany

8,439

21,463

Tioga

9,203

22,260

Guilford

7,650

21,582

Allegany

8,449

20,437

Tompkins

9,203

22,260

Halifax

7,967

22,994

Bronx

11,243

29,771

Ulster

10,472

25,016

Harnett

7,391

23,420

Broome

9,203

22,260

Warren

8,439

21,463

Haywood

8,305

21,752

Cattaraugus

8,449

20,437

Washington

8,439

21,463

Henderson

8,305

21,752

Cayuga

9,203

22,260

Wayne

8,103

20,885

Hertford

7,967

22,994

Chautauqua

8,449

20,437

Westchester

11,243

29,771

Hoke

7,391

23,420

Chemung

9,203

22,260

Wyoming

8,449

20,437

Hyde

9,047

21,390

Chenango

9,203

25,195

Yates

8,103

20,885

Iredell

7,960

21,585

Clinton

9,203

25,195

Jackson

8,305

21,752

Columbia

8,439

21,463

Cortland

9,203

22,260

Delaware

10,472

25,016

Dutchess

10,472

Erie

North Carolina

Johnston

7,278

22,091

Jones

9,047

21,390

County

Employee- Dependent,
Only
Family, etc.

Lee

7,851

25,284

25,016

Alamance

7,851

25,284

Lenoir

9,047

21,390

8,449

20,437

Alexander

7,960

21,585

Lincoln

8,254

22,198

Essex

9,203

25,195

Alleghany

8,494

23,965

Macon

8,305

21,752

Franklin

9,203

25,195

Anson

7,893

22,733

Madison

8,305

21,752

Fulton

8,439

21,463

Ashe

8,494

23,965

Martin

7,967

22,994

Genesee

8,449

20,437

Avery

8,305

21,752

McDowell

8,305

21,752

Greene

8,439

21,463

Beaufort

9,047

21,390

Mecklenburg

7,893

22,733

2023 Average Premium Tables

-23-

Mitchell

8,305

21,752

Cavalier

8,478

24,547

Auglaize

8,334

21,287

Montgomery

9,310

22,169

Dickey

8,478

24,547

Belmont

7,905

19,458

Moore

9,310

22,169

Divide

8,478

24,547

Brown

7,700

19,544

Nash

8,970

27,984

Dunn

8,478

24,547

Butler

7,872

23,435

New Hanover

7,906

21,413

Eddy

8,478

24,547

Carroll

7,693

22,733

Northampton

7,967

22,994

Emmons

8,478

24,547

Champaign

7,552

21,207

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Onslow

7,906

21,413

Foster

8,478

24,547

Clark

7,552

21,207

Orange

7,851

25,284

Golden Valley

8,478

24,547

Clermont

7,700

19,544

Pamlico

9,047

21,390

Grand Forks

7,369

23,920

Clinton

7,700

19,544

Pasquotank

7,967

22,994

Grant

8,478

24,547

Columbiana

7,575

21,064

Pender

7,906

21,413

Griggs

8,478

24,547

Coshocton

7,905

19,458

Perquimans

7,967

22,994

Hettinger

8,478

24,547

Crawford

7,799

20,711

Person

7,851

25,284

Kidder

8,478

24,547

Cuyahoga

8,331

23,234

Pitt

8,970

27,984

La Moure

8,478

24,547

Darke

7,552

21,207

Polk

8,305

21,752

Logan

8,478

24,547

Defiance

8,137

21,370

Randolph

7,650

21,582

McHenry

8,478

24,547

Delaware

7,351

22,087

Richmond

7,391

23,420

McIntosh

8,478

24,547

Erie

8,591

22,268

Robeson

7,391

23,420

McKenzie

8,478

24,547

Fairfield

7,351

22,087

Rockingham

7,650

21,582

McLean

8,478

24,547

Fayette

7,351

22,087

Rowan

7,893

22,733

Mercer

8,478

24,547

Franklin

7,351

22,087

Rutherford

8,305

21,752

Morton

8,214

23,849

Fulton

8,137

21,370

Sampson

7,391

23,420

Mountrail

8,478

24,547

Gallia

9,816

25,764

Scotland

7,391

23,420

Nelson

8,478

24,547

Geauga

8,331

23,234

Stanly

7,893

22,733

Oliver

8,478

24,547

Greene

7,552

21,207

Stokes

8,418

23,593

Pembina

8,478

24,547

Guernsey

7,905

19,458

Surry

8,418

23,593

Pierce

8,478

24,547

Hamilton

7,872

23,435

Swain

8,305

21,752

Ramsey

8,478

24,547

Hancock

8,334

21,287

Transylvania

8,305

21,752

Ransom

8,478

24,547

Hardin

8,334

21,287

Tyrrell

9,047

21,390

Renville

8,478

24,547

Harrison

7,905

19,458

Union

7,893

22,733

Richland

8,478

24,547

Henry

8,137

21,370

Vance

7,403

20,823

Rolette

8,478

24,547

Highland

7,700

19,544

Wake

7,278

22,091

Sargent

8,478

24,547

Hocking

8,183

21,428

Warren

7,403

20,823

Sheridan

8,478

24,547

Holmes

6,481

20,621

Washington

9,047

21,390

Sioux

8,478

24,547

Huron

8,591

22,268

Watauga

8,494

23,965

Slope

8,478

24,547

Jackson

9,816

25,764

Wayne

8,970

27,984

Stark

8,478

24,547

Jefferson

7,905

19,458

Wilkes

8,494

23,965

Steele

8,478

24,547

Knox

7,351

22,087

Wilson

8,970

27,984

Stutsman

8,478

24,547

Lake

8,331

23,234

Yadkin

8,418

23,593

Towner

8,478

24,547

Lawrence

9,816

25,764

Yancey

8,305

21,752

Traill

8,478

24,547

Licking

7,351

22,087

Walsh

8,478

24,547

Logan

7,351

22,087

Ward

8,478

24,547

Lorain

8,331

23,234

Wells

8,478

24,547

Lucas

8,137

21,370

Williams

8,478

24,547

Madison

7,351

22,087

Mahoning

7,575

21,064

Marion

7,861

21,747

North Dakota
County

Employee- Dependent,
Only
Family, etc.

Adams

8,478

24,547

Barnes

8,478

24,547

Benson

8,478

24,547

8,141

22,928

8,478

24,547

County

Employee- Dependent,
Only
Family, etc.

Medina

Billings

Meigs

8,183

21,428

Bottineau

8,478

24,547

Adams

7,700

19,544

Mercer

8,334

21,287

Bowman

8,478

24,547

Allen

8,334

21,287

Miami

7,552

21,207

Burke

8,478

24,547

Ashland

8,141

22,928

Monroe

7,905

19,458

Burleigh

8,214

23,849

Ashtabula

8,331

23,234

Montgomery

7,552

21,207

Cass

7,707

24,039

Athens

8,183

21,428

Morgan

7,905

19,458

Ohio

-24-

2023 Average Premium Tables

Morrow

7,861

21,747

Custer

8,126

22,340

Wagoner

8,397

22,134

Muskingum

7,905

19,458

Delaware

8,126

22,340

Washington

8,126

22,340

Noble

7,905

19,458

Dewey

8,126

22,340

Washita

8,126

22,340

Ottawa

8,591

22,268

Ellis

8,126

22,340

Woods

8,126

22,340

Paulding

8,334

21,287

Garfield

8,126

22,340

Woodward

8,126

22,340

Perry

7,905

19,458

Garvin

8,126

22,340

Oregon

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Pickaway

7,351

22,087

Grady

8,463

21,112

Pike

9,816

25,764

Grant

8,126

22,340

Portage

8,141

22,928

Greer

8,126

22,340

County

Employee- Dependent,
Only
Family, etc.

Preble

7,552

21,207

Harmon

8,126

22,340

Baker

9,689

24,154

7,925

21,095

Putnam

8,334

21,287

Harper

8,126

22,340

Benton

Richland

7,799

20,711

Haskell

8,126

22,340

Clackamas

7,421

22,379

22,340

Clatsop

9,288

23,313

9,288

23,313

Ross

9,816

25,764

Hughes

8,126

Sandusky

8,591

22,268

Jackson

8,126

22,340

Columbia

Scioto

9,816

25,764

Jefferson

8,126

22,340

Coos

9,288

23,313

22,340

Crook

9,689

24,154

9,288

23,313

Seneca

8,591

22,268

Johnston

8,126

Shelby

7,552

21,207

Kay

8,126

22,340

Curry

Stark

7,693

22,733

Kingfisher

8,126

22,340

Deschutes

8,511

23,403

8,028

22,230

Summit

8,141

22,928

Kiowa

8,126

22,340

Douglas

Trumbull

7,575

21,064

Latimer

8,126

22,340

Gilliam

9,689

24,154

Tuscarawas

7,905

19,458

Le Flore

7,472

19,440

Grant

9,689

24,154

9,689

24,154

Union

7,351

22,087

Lincoln

8,463

21,112

Harney

Van Wert

8,334

21,287

Logan

8,463

21,112

Hood River

9,689

24,154

22,340

Jackson

8,028

22,230

9,689

24,154

Vinton

9,816

25,764

Love

8,126

Warren

7,872

23,435

Major

8,126

22,340

Jefferson

Washington

8,183

21,428

Marshall

8,126

22,340

Josephine

8,028

22,230

22,340

Klamath

8,511

23,403

8,511

23,403

Wayne

6,481

20,621

Mayes

8,126

Williams

8,137

21,370

McClain

8,463

21,112

Lake

Wood

8,137

21,370

McCurtain

8,126

22,340

Lane

7,925

21,095

22,340

Lincoln

9,288

23,313

7,925

21,095

Wyandot

8,591

22,268

Oklahoma

McIntosh

8,126

Murray

8,126

22,340

Linn

Muskogee

8,126

22,340

Malheur

9,689

24,154

22,340

Marion

7,547

21,686

9,689

24,154

Noble

County

Employee- Dependent,
Only
Family, etc.

Nowata

8,126

22,340

Morrow

Adair

8,126

22,340

Okfuskee

8,126

22,340

Multnomah

7,421

22,379

Alfalfa

8,126

22,340

Oklahoma

8,463

21,112

Polk

7,547

21,686

Atoka

8,126

22,340

Okmulgee

8,397

22,134

Sherman

9,689

24,154

Beaver

8,126

22,340

Osage

8,397

22,134

Tillamook

9,288

23,313

Beckham

8,126

22,340

Ottawa

8,126

22,340

Umatilla

9,689

24,154

Blaine

8,126

22,340

Pawnee

8,397

22,134

Union

9,689

24,154

Bryan

8,126

22,340

Payne

8,126

22,340

Wallowa

9,689

24,154

Caddo

8,126

22,340

Pittsburg

8,126

22,340

Wasco

9,689

24,154

Canadian

8,463

21,112

Pontotoc

8,126

22,340

Washington

7,421

22,379

Carter

8,126

22,340

22,340

Wheeler

9,689

24,154

Cherokee

8,126

22,340

Pushmataha

8,126

22,340

Yamhill

7,421

22,379

Choctaw

8,126

22,340

Roger Mills

8,126

22,340

Cimarron

8,126

22,340

Rogers

8,397

22,134

Cleveland

8,463

21,112

Seminole

8,126

22,340

Coal

8,126

22,340

Sequoyah

7,472

19,440

Comanche

7,985

20,401

Stephens

8,126

22,340

Texas

8,126

22,340

Cotton

8,126

22,340

Pottawatomie

8,126

8,126

Craig

8,126

22,340

Tillman

8,126

22,340

Creek

8,397

22,134

Tulsa

8,397

22,134

2023 Average Premium Tables

-25-

Pennsylvania
County

Employee- Dependent,
Only
Family, etc.

Adams

8,983

24,095

Allegheny

8,022

22,027

Armstrong

8,022

22,027

Beaver

8,022

22,027

Bedford

8,469

20,575

Susquehanna

8,137

23,020

McCormick

8,590

22,973

Berks

8,983

24,095

Tioga

8,137

23,020

Newberry

8,550

22,352

Blair

8,469

20,575

Union

8,694

26,717

Oconee

9,341

25,843

Bradford

8,137

23,020

Venango

7,425

20,206

Orangeburg

8,291

23,112

Bucks

8,596

23,467

Warren

7,425

20,206

Pickens

7,983

22,026

Butler

8,022

22,027

Washington

8,022

22,027

Richland

8,074

23,003

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Cambria

8,469

20,575

Wayne

8,137

23,020

Saluda

8,422

22,368

Cameron

7,314

22,737

Westmoreland

8,022

22,027

Spartanburg

7,709

22,457

Carbon

8,137

23,020

Wyoming

8,137

23,020

Sumter

7,846

20,767

Centre

8,694

26,717

York

8,983

24,095

Union

7,512

21,717

Chester

8,596

23,467

Williamsburg

7,776

22,421

Clarion

7,425

20,206

York

7,868

22,286

Clearfield

8,469

20,575

Clinton

8,137

23,020

County

Employee- Dependent,
Only
Family, etc.

Columbia

8,694

26,717

All

8,796

Crawford

7,425

20,206

Cumberland

8,863

24,699

Dauphin

8,863

24,699

Delaware

8,596

23,467

Elk

7,314

22,737

Erie

7,425

20,206

Fayette

8,022

22,027

Forest

7,425

20,206

Franklin

8,863

24,699

Fulton

8,863

24,699

Greene

8,022

22,027

Huntingdon

8,469

20,575

Indiana

8,022

22,027

Jefferson

8,469

20,575

Juniata

8,863

24,699

Lackawanna

8,137

23,020

Lancaster

8,983

24,095

Lawrence

8,022

22,027

Lebanon

8,863

24,699

Lehigh

8,694

26,717

Luzerne

8,137

23,020

Lycoming

8,137

23,020

McKean

7,425

20,206

Mercer

7,425

20,206

Mifflin

8,694

26,717

Monroe

8,137

23,020

Montgomery

8,596

23,467

Montour

8,694

26,717

Northampton

8,694

26,717

Northumberland

8,694

26,717

Perry

8,863

24,699

Philadelphia

8,596

23,467

Pike

8,137

23,020

Potter

7,314

22,737

Schuylkill

8,694

26,717

Snyder

8,694

26,717

Somerset

8,469

20,575

Sullivan

8,137

23,020

Rhode Island

South Dakota

24,780

South Carolina

County

Employee- Dependent,
Only
Family, etc.

Aurora

8,365

24,641

Employee- Dependent,
Only
Family, etc.

Beadle

7,952

23,411

County

Bennett

7,735

21,478

Abbeville

8,099

22,442

Bon Homme

8,365

24,641

Aiken

7,627

21,404

Brookings

7,952

23,411

Allendale

7,955

22,061

Brown

7,952

23,411

Anderson

8,023

22,069

Brule

8,365

24,641

Bamberg

7,536

22,564

Buffalo

8,365

24,641

Barnwell

7,463

21,743

Butte

7,735

21,478

Beaufort

8,126

21,663

Campbell

7,952

23,411

Berkeley

8,717

21,748

Charles Mix

8,365

24,641

Calhoun

7,775

22,009

Clark

7,952

23,411

Charleston

7,808

22,902

Clay

7,477

21,356

Cherokee

7,663

22,225

Codington

7,952

23,411

Chester

8,071

21,886

Corson

7,735

21,478

Chesterfield

7,988

22,551

Custer

7,735

21,478

Clarendon

7,369

21,976

Davison

8,365

24,641

Colleton

8,068

23,075

Day

7,952

23,411

Darlington

8,319

22,772

Deuel

7,952

23,411

Dillon

8,040

21,490

Dewey

7,735

21,478

Dorchester

9,023

22,684

Douglas

8,365

24,641

Edgefield

7,449

22,065

Edmunds

7,952

23,411

Fairfield

7,982

22,308

Fall River

7,735

21,478

Florence

8,165

22,796

Faulk

7,952

23,411

Georgetown

8,100

21,834

Grant

7,952

23,411

Greenville

8,011

22,390

Gregory

7,735

21,478

Greenwood

7,464

22,222

Haakon

7,735

21,478

Hampton

8,305

22,455

Hamlin

7,952

23,411

Horry

7,496

22,581

Hand

8,365

24,641

Jasper

7,826

22,874

Hanson

8,365

24,641

Kershaw

8,349

22,207

Harding

7,735

21,478

Lancaster

8,029

21,741

Hughes

8,365

24,641

Laurens

7,684

21,804

Hutchinson

8,365

24,641

Lee

7,814

22,307

Hyde

8,365

24,641

Lexington

8,215

22,393

Jackson

7,735

21,478

Marion

8,491

23,343

Jerauld

8,365

24,641

Marlboro

8,036

22,442

Jones

7,735

21,478

-26-

2023 Average Premium Tables

Kingsbury

7,952

23,411

DeKalb

6,672

16,567

Robertson

7,695

19,360

Lake

7,477

21,356

Dickson

7,001

18,618

Rutherford

7,695

19,360

Lawrence

7,735

21,478

Dyer

7,401

20,883

Scott

6,720

17,996

Lincoln

7,477

21,356

Fayette

7,276

18,799

Sequatchie

7,379

18,618

Lyman

7,735

21,478

Fentress

6,672

16,567

Sevier

6,720

17,996

Marshall

7,952

23,411

Franklin

7,379

18,618

Shelby

7,276

18,799

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
McCook

7,477

21,356

Gibson

7,401

20,883

Smith

6,672

16,567

McPherson

7,952

23,411

Giles

7,001

18,618

Stewart

7,001

18,618

Meade

7,735

21,478

Grainger

6,720

17,996

Sullivan

7,434

18,852

Mellette

7,735

21,478

Greene

7,434

18,852

Sumner

7,695

19,360

Miner

8,365

24,641

Grundy

7,379

18,618

Tipton

7,276

18,799

Minnehaha

7,477

21,356

Hamblen

6,720

17,996

Trousdale

7,695

19,360

Moody

7,477

21,356

Hamilton

7,379

18,618

Unicoi

7,434

18,852

Pennington

7,735

21,478

Hancock

7,434

18,852

Union

6,720

17,996

Perkins

7,735

21,478

Hardeman

7,401

20,883

Van Buren

6,672

16,567

Potter

7,952

23,411

Hardin

7,401

20,883

Warren

6,672

16,567

Roberts

7,952

23,411

Hawkins

7,434

18,852

Washington

7,434

18,852

Sanborn

8,365

24,641

Haywood

7,276

18,799

Wayne

7,001

18,618

Shannon

7,735

21,478

Henderson

7,401

20,883

Weakley

7,401

20,883

Spink

7,952

23,411

Henry

7,401

20,883

White

6,672

16,567

Stanley

7,735

21,478

Hickman

7,001

18,618

Williamson

7,695

19,360

Sully

8,365

24,641

Houston

7,001

18,618

Wilson

7,695

19,360

Todd

7,735

21,478

Humphreys

7,001

18,618

Tripp

7,735

21,478

Jackson

6,672

16,567

Turner

7,477

21,356

Jefferson

6,720

17,996

Union

7,477

21,356

Johnson

7,434

18,852

County

Employee- Dependent,
Only
Family, etc.

Walworth

7,952

23,411

Knox

6,720

17,996

Anderson

7,822

20,066

7,822

20,066

Texas

Yankton

8,365

24,641

Lake

7,401

20,883

Andrews

Ziebach

7,735

21,478

Lauderdale

7,276

18,799

Angelina

7,822

20,066

18,618

Aransas

8,102

26,628

8,440

20,716

Lawrence

Tennessee
County

Employee- Dependent,
Only
Family, etc.

7,001

Lewis

7,001

18,618

Archer

Lincoln

7,001

18,618

Armstrong

10,030

23,705

17,996

Atascosa

7,665

18,955

7,250

22,662

Loudon

6,720

Anderson

6,720

17,996

Macon

6,672

16,567

Austin

Bedford

7,001

18,618

Madison

7,401

20,883

Bailey

7,822

20,066

Benton

7,401

20,883

Marion

7,379

18,618

Bandera

7,665

18,955

Bledsoe

7,379

18,618

Marshall

7,001

18,618

Bastrop

7,061

20,191

Blount

6,720

17,996

Maury

7,001

18,618

Baylor

7,822

20,066

Bradley

7,379

18,618

McMinn

7,379

18,618

Bee

7,822

20,066

Campbell

6,720

17,996

McNairy

7,401

20,883

Bell

8,124

18,547

Cannon

6,672

16,567

Meigs

7,379

18,618

Bexar

7,665

18,955

Carroll

7,401

20,883

Monroe

6,720

17,996

Blanco

7,822

20,066

Carter

7,434

18,852

Montgomery

7,695

19,360

Borden

7,822

20,066

Cheatham

7,695

19,360

18,618

Bosque

7,822

20,066

Chester

7,401

20,883

Morgan

6,720

17,996

Bowie

7,368

20,522

Claiborne

6,720

17,996

Obion

7,401

20,883

Brazoria

7,250

22,662

Clay

6,672

16,567

16,567

Brazos

7,118

20,305

Cocke

6,720

17,996

Perry

7,001

18,618

Brewster

7,822

20,066

Coffee

7,001

18,618

Pickett

6,672

16,567

Briscoe

7,822

20,066

Crockett

7,401

20,883

18,618

Brooks

7,822

20,066

7,822

20,066

Moore

Overton

Polk

7,001

6,672

7,379

Cumberland

6,672

16,567

Putnam

6,672

16,567

Brown

Davidson

7,695

19,360

Rhea

7,379

18,618

Burleson

7,118

20,305

Decatur

7,401

20,883

17,996

Burnet

7,822

20,066

2023 Average Premium Tables

Roane

6,720

-27-

Caldwell

7,061

20,191

Freestone

7,822

20,066

Kimble

7,822

20,066

Calhoun

8,198

21,897

Frio

7,822

20,066

King

7,822

20,066

Callahan

7,456

20,335

Gaines

7,822

20,066

Kinney

7,822

20,066

Cameron

6,716

18,893

Galveston

7,250

22,662

Kleberg

7,822

20,066

Camp

7,822

20,066

Garza

7,822

20,066

Knox

7,822

20,066

Carson

10,030

23,705

Gillespie

7,822

20,066

Lamar

7,822

20,066

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Cass

7,822

20,066

Glasscock

7,822

20,066

Lamb

7,822

20,066

Castro

7,822

20,066

Goliad

8,198

21,897

Lampasas

8,124

18,547

Chambers

7,250

22,662

Gonzales

7,822

20,066

LaSalle

7,822

20,066

Cherokee

7,822

20,066

Gray

7,822

20,066

Lavaca

7,822

20,066

Childress

7,822

20,066

Grayson

7,707

19,921

Lee

7,822

20,066

Clay

8,440

20,716

Gregg

6,632

22,987

Leon

7,822

20,066

Cochran

7,822

20,066

Grimes

7,822

20,066

Liberty

7,250

22,662

Coke

7,822

20,066

Guadalupe

7,665

18,955

Limestone

7,822

20,066

Coleman

7,822

20,066

Hale

7,822

20,066

Lipscomb

7,822

20,066

Collin

7,978

22,164

Hall

7,822

20,066

Live Oak

7,822

20,066

Collingsworth

7,822

20,066

Hamilton

7,822

20,066

Llano

7,822

20,066

Colorado

7,822

20,066

Hansford

7,822

20,066

Loving

7,822

20,066

Comal

7,665

18,955

Hardeman

7,822

20,066

Lubbock

7,143

21,917

Comanche

7,822

20,066

Hardin

9,052

22,480

Lynn

7,822

20,066

Concho

7,822

20,066

Harris

7,250

22,662

Madison

7,822

20,066

Cooke

7,822

20,066

Harrison

7,822

20,066

Marion

7,822

20,066

Coryell

8,124

18,547

Hartley

7,822

20,066

Martin

7,822

20,066

Cottle

7,822

20,066

Haskell

7,822

20,066

Mason

7,822

20,066

Crane

7,822

20,066

Hays

7,061

20,191

Matagorda

7,822

20,066

Crockett

7,822

20,066

Hemphill

7,822

20,066

Maverick

7,822

20,066

Crosby

7,143

21,917

Henderson

7,822

20,066

McCulloch

7,822

20,066

Culberson

7,822

20,066

Hidalgo

8,613

21,323

McLennan

5,891

17,785

Dallam

7,822

20,066

Hill

7,822

20,066

McMullen

7,822

20,066

Dallas

7,978

22,164

Hockley

7,822

20,066

Medina

7,665

18,955

Dawson

7,822

20,066

Hood

7,822

20,066

Menard

7,822

20,066

Deaf Smith

7,822

20,066

Hopkins

7,822

20,066

Midland

6,913

22,892

Delta

7,978

22,164

Houston

7,822

20,066

Milam

7,822

20,066

Denton

7,978

22,164

Howard

7,822

20,066

Mills

7,822

20,066

DeWitt

7,822

20,066

Hudspeth

7,822

20,066

Mitchell

7,822

20,066

Dickens

7,822

20,066

Hunt

7,978

22,164

Montague

7,822

20,066

Dimmit

7,822

20,066

Hutchinson

7,822

20,066

Montgomery

7,250

22,662

Donley

7,822

20,066

Irion

10,151

23,008

Moore

7,822

20,066

Duval

7,822

20,066

Jack

7,822

20,066

Morris

7,822

20,066

Eastland

7,822

20,066

Jackson

7,822

20,066

Motley

7,822

20,066

Ector

8,911

19,166

Jasper

7,822

20,066

Nacogdoches

7,822

20,066

Edwards

7,822

20,066

Jeff Davis

7,822

20,066

Navarro

7,822

20,066

El Paso

7,581

16,149

Jefferson

9,052

22,480

Newton

7,822

20,066

Ellis

7,978

22,164

Jim Hogg

7,822

20,066

Nolan

7,822

20,066

Erath

7,822

20,066

Jim Wells

7,822

20,066

Nueces

8,102

26,628

Falls

7,822

20,066

Johnson

7,978

22,164

Ochiltree

7,822

20,066

Fannin

7,822

20,066

Jones

7,456

20,335

Oldham

7,822

20,066

Fayette

7,822

20,066

Karnes

7,822

20,066

Orange

9,052

22,480

Fisher

7,822

20,066

Kaufman

7,978

22,164

Palo Pinto

7,822

20,066

Floyd

7,822

20,066

Kendall

7,665

18,955

Panola

7,822

20,066

Foard

7,822

20,066

Kenedy

7,822

20,066

Parker

7,978

22,164

Fort Bend

7,250

22,662

Kent

7,822

20,066

Parmer

7,822

20,066

Franklin

7,822

20,066

Kerr

7,822

20,066

Pecos

7,822

20,066

-28-

2023 Average Premium Tables

Virginia

Polk

7,822

20,066

Webb

8,091

21,227

Potter

10,030

23,705

Wharton

7,822

20,066

Presidio

7,822

20,066

Wheeler

7,822

20,066

County

Employee- Dependent,
Only
Family, etc.

Rains

7,822

20,066

Wichita

8,440

20,716

Accomack

7,539

20,308

Randall

10,030

23,705

Wilbarger

7,822

20,066

Albemarle

8,974

21,460

Reagan

7,822

20,066

Willacy

7,822

20,066

Alexandria City

8,021

23,327

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Real

7,822

20,066

Williamson

7,061

20,191

Alleghany

7,539

20,308

Red River

7,822

20,066

Wilson

7,665

18,955

Amelia

7,693

22,408

Reeves

7,822

20,066

Winkler

7,822

20,066

Amherst

6,642

20,171

6,642

20,171

Refugio

7,822

20,066

Wise

7,978

22,164

Appomattox

Roberts

7,822

20,066

Wood

7,822

20,066

Arlington

8,021

23,327

Robertson

7,118

20,305

Yoakum

7,822

20,066

Augusta

7,539

20,308

7,539

20,308

Rockwall

7,978

22,164

Young

7,822

20,066

Bath

Runnels

7,822

20,066

Zapata

7,822

20,066

Bedford

6,642

20,171

Rusk

6,632

22,987

Zavala

7,822

20,066

Bedford City

6,642

20,171

Bland

7,539

20,308

Botetourt

8,194

22,437

7,843

19,493

Sabine

7,822

20,066

San Augustine

7,822

20,066

San Jacinto

7,250

22,662

Utah

Employee- Dependent,
Only
Family, etc.

Bristol City

San Patricio

8,102

26,628

County

Brunswick

7,539

20,308

San Saba

7,822

20,066

Beaver

7,720

23,521

Buchanan

7,539

20,308

Schleicher

7,822

20,066

Box Elder

7,158

22,242

Buckingham

7,539

20,308

8,509

23,989

Scurry

7,822

20,066

Cache

Buena Vista City

7,539

20,308

Shackelford

7,822

20,066

Carbon

7,720

23,521

Campbell

6,642

20,171

20,066

Daggett

7,720

23,521

Caroline

7,693

22,408

7,291

22,868

Shelby

7,822

Sherman

7,822

20,066

Davis

Carroll

7,539

20,308

Smith

7,669

22,893

Duchesne

7,720

23,521

Charles City

7,693

22,408

20,066

Emery

7,720

23,521

Charlotte

7,539

20,308

7,720

23,521

Somervell

7,822

Starr

7,822

20,066

Garfield

Charlottesville City

8,974

21,460

Stephens

7,822

20,066

Grand

7,720

23,521

Chesapeake City

7,782

21,119

20,066

Iron

9,091

22,531

Chesterfield

7,693

22,408

7,720

23,521

Sterling

7,822

Stonewall

7,822

20,066

Juab

Clarke

8,021

23,327

Sutton

7,822

20,066

Kane

7,720

23,521

Colonial Heights City

7,693

22,408

20,066

Millard

7,720

23,521

Covington City

7,539

20,308

7,158

22,242

Swisher

7,822

Tarrant

7,978

22,164

Morgan

Craig

8,194

22,437

Taylor

7,456

20,335

Piute

7,720

23,521

Culpeper

7,539

20,308

8,509

23,989

Terrell

7,822

20,066

Rich

Cumberland

7,693

22,408

Terry

7,822

20,066

Salt Lake

7,291

22,868

Danville City

8,956

21,176

Throckmorton

7,822

20,066

San Juan

7,720

23,521

Dickenson

7,539

20,308

7,720

23,521

Titus

7,822

20,066

Sanpete

Dinwiddie

7,693

22,408

Tom Green

10,151

23,008

Sevier

7,720

23,521

Emporia City

7,539

20,308

Travis

7,061

20,191

Summit

7,291

22,868

Essex

7,539

20,308

7,291

22,868

Trinity

7,822

20,066

Tooele

Fairfax

8,021

23,327

Tyler

7,822

20,066

Uintah

7,720

23,521

Fairfax City

8,021

23,327

22,987

Utah

6,933

22,542

Falls Church City

8,021

23,327

7,291

22,868

Upshur

6,632

Upton

7,822

20,066

Wasatch

Fauquier

8,021

23,327

Uvalde

7,822

20,066

Washington

9,091

22,531

Floyd

7,539

20,308

20,066

Wayne

7,720

23,521

Fluvanna

8,974

21,460

Weber

7,158

22,242

Franklin

8,194

22,437

Franklin City

7,539

20,308

Frederick

8,090

21,890

Fredericksburg City

8,021

23,327

Galax City

7,539

20,308

Giles

6,887

20,744

Val Verde

7,822

Van Zandt

7,822

20,066

Victoria

8,198

21,897

Walker

7,822

20,066

Waller

7,250

22,662

Ward

7,822

20,066

Washington

7,822

20,066

2023 Average Premium Tables

Vermont
County

Employee- Dependent,
Only
Family, etc.

All

8,460

-29-

23,240

Gloucester

7,782

21,119

Radford City

6,887

20,744

Kittitas

7,672

22,822

Goochland

7,693

22,408

Rappahannock

7,539

20,308

Klickitat

7,145

20,391

Grayson

7,539

20,308

Richmond

7,539

20,308

Lewis

7,967

20,803

Greene

8,974

21,460

Richmond City

7,693

22,408

Lincoln

7,417

19,788

Greensville

7,539

20,308

Roanoke

8,194

22,437

Mason

7,967

20,803

Halifax

7,539

20,308

Roanoke City

8,194

22,437

Okanogan

7,672

22,822

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Hampton City

7,782

21,119

Rockbridge

7,539

20,308

Pacific

7,967

20,803

Hanover

7,693

22,408

Rockingham

7,253

21,742

Pend Oreille

7,417

19,788

Harrisonburg City

7,253

21,742

Russell

7,539

20,308

Pierce

7,967

20,803

Henrico

7,693

22,408

Salem City

8,194

22,437

San Juan

7,967

20,803

Henry

7,539

20,308

Scott

7,843

19,493

Skagit

7,967

20,803

Highland

7,539

20,308

Shenandoah

7,539

20,308

Skamania

7,145

20,391

Hopewell City

7,693

22,408

Smyth

7,539

20,308

Snohomish

7,967

20,803

Isle of Wight

7,782

21,119

Southampton

7,539

20,308

Spokane

7,417

19,788

James City

7,782

21,119

Spotsylvania

8,021

23,327

Stevens

7,417

19,788

King and Queen

7,693

22,408

Stafford

8,021

23,327

Thurston

7,967

20,803

King George

7,539

20,308

Staunton City

7,539

20,308

Wahkiakum

7,967

20,803

King William

7,693

22,408

Suffolk City

7,782

21,119

Walla Walla

7,672

22,822

Lancaster

7,539

20,308

Surry

7,782

21,119

Whatcom

7,967

20,803

Lee

7,539

20,308

Sussex

7,693

22,408

Whitman

7,672

22,822

Lexington City

7,539

20,308

Tazewell

7,539

20,308

Yakima

7,672

22,822

Loudoun

8,021

23,327

Virginia Beach City

7,782

21,119

Louisa

7,693

22,408

Warren

8,021

23,327

Lunenburg

7,539

20,308

Washington

7,843

19,493

Lynchburg City

6,642

20,171

Waynesboro City

7,539

20,308

County

Employee- Dependent,
Only
Family, etc.

Madison

7,539

20,308

Westmoreland

7,539

20,308

Barbour

9,242

27,010

21,119

Berkeley

8,573

24,140

8,389

26,140

Manassas City

8,021

23,327

Williamsburg City

7,782

West Virginia

Manassas Park City

8,021

23,327

Winchester City

8,090

21,890

Boone

Martinsville City

7,539

20,308

Wise

7,539

20,308

Braxton

9,567

25,392

20,308

Brooke

8,840

27,737

21,119

Cabell

8,675

25,542

Calhoun

9,567

25,392

Clay

9,567

25,392

Doddridge

9,107

24,704

Mathews

7,782

21,119

Mecklenburg

7,539

20,308

Middlesex

7,539

20,308

Montgomery

6,887

20,744

Wythe
York

7,539
7,782

Washington

Nelson

8,974

21,460

New Kent

7,693

22,408

County

Employee- Dependent,
Only
Family, etc.

Fayette

9,567

25,392

7,672

22,822

Gilmer

9,107

24,704

Newport News City

7,782

21,119

Adams

Norfolk City

7,782

21,119

Asotin

7,672

22,822

Grant

7,539

24,907

Northampton

7,539

20,308

Benton

7,672

22,822

Greenbrier

9,567

25,392

7,672

22,822

Hampshire

7,539

24,907

Northumberland

7,539

20,308

Chelan

Norton City

7,539

20,308

Clallam

7,967

20,803

Hancock

8,840

27,737

Nottoway

7,539

20,308

Clark

7,145

20,391

Hardy

7,539

24,907

7,672

22,822

Harrison

9,242

27,010

Orange

7,539

20,308

Columbia

Page

7,539

20,308

Cowlitz

7,967

20,803

Jackson

9,704

28,051

20,308

Douglas

7,672

22,822

Jefferson

8,573

24,140

7,417

19,788

Kanawha

10,466

28,870

Patrick

7,539

Petersburg City

7,693

22,408

Ferry

Pittsylvania

8,956

21,176

Franklin

7,672

22,822

Lewis

9,107

24,704

21,119

Garfield

7,672

22,822

Lincoln

8,389

26,140

7,672

22,822

Logan

8,389

26,140

Poquoson

7,782

Portsmouth City

7,782

21,119

Grant

Powhatan

7,693

22,408

Grays Harbor

7,967

20,803

Marion

9,107

24,704

20,308

Island

7,967

20,803

Marshall

8,840

27,737

7,967

20,803

Mason

8,675

25,542

Prince Edward

7,539

Prince George

7,693

22,408

Jefferson

Prince William

8,021

23,327

King

7,851

21,509

McDowell

8,389

26,140

20,744

Kitsap

7,967

20,803

Mercer

8,780

21,360

Pulaski

6,887

-30-

2023 Average Premium Tables

Mineral

7,539

24,907

Dodge

7,712

22,786

Sawyer

9,003

25,622

Mingo

8,389

26,140

Door

7,748

22,230

Shawano

7,748

22,230

Monongalia

9,107

24,704

Douglas

9,003

25,622

Sheboygan

7,712

22,786

Monroe

8,780

21,360

Dunn

8,268

24,992

St. Croix

9,799

25,801

Morgan

7,539

24,907

Eau Claire

8,268

24,992

Taylor

8,104

22,602

Nicholas

9,567

25,392

Florence

6,695

21,458

Trempealeau

7,925

22,747

TREASURY/IRS
AND OMB USE
ONLY DRAFT
November 13, 2023
Ohio

8,840

27,737

Fond du Lac

7,712

22,786

Vernon

8,133

23,995

Pendleton

7,539

24,907

Forest

6,695

21,458

Vilas

6,695

21,458

Pleasants

9,704

28,051

Grant

8,133

23,995

Walworth

8,344

26,080

Pocahontas

9,242

27,010

Green

8,344

26,080

Washburn

9,003

25,622

Preston

9,242

27,010

Green Lake

8,246

29,125

Washington

8,177

24,978

Putnam

8,675

25,542

Iowa

8,133

23,995

Waukesha

8,177

24,978

Raleigh

8,780

21,360

Iron

6,695

21,458

Waupaca

7,712

22,786

Randolph

9,242

27,010

Jackson

7,925

22,747

Waushara

7,712

22,786

Ritchie

9,704

28,051

Jefferson

8,344

26,080

Winnebago

7,712

22,786

Roane

9,567

25,392

Juneau

8,246

29,125

Wood

9,019

25,476

Summers

8,780

21,360

Kenosha

9,382

26,795

Taylor

9,242

27,010

Kewaunee

7,748

22,230

Tucker

9,242

27,010

La Crosse

7,925

22,747

Tyler

9,704

28,051

Lafayette

8,133

23,995

County

Employee- Dependent,
Only
Family, etc.

Upshur

9,242

27,010

Langlade

6,695

21,458

Albany

8,863

24,339

8,863

24,339

Wyoming

Wayne

8,675

25,542

Lincoln

9,019

25,476

Big Horn

Webster

9,242

27,010

Manitowoc

7,748

22,230

Campbell

8,863

24,339

25,476

Carbon

8,863

24,339

8,863

24,339

Wetzel

9,107

24,704

Marathon

9,019

Wirt

9,704

28,051

Marinette

7,748

22,230

Converse

Wood

9,704

28,051

Marquette

8,246

29,125

Crook

8,863

24,339

22,230

Fremont

8,863

24,339

8,863

24,339

Wyoming

8,389

26,140

Wisconsin

Menomonee

7,748

Milwaukee

7,939

26,745

Goshen

Monroe

7,925

22,747

Hot Springs

8,863

24,339

22,230

Johnson

8,863

24,339

8,671

22,222

Employee- Dependent,
Only
Family, etc.

Oconto

County

Oneida

6,695

21,458

Laramie

Adams

8,246

29,125

Outagamie

7,712

22,786

Lincoln

8,863

24,339

Ashland

9,003

25,622

24,978

Natrona

9,630

24,281

8,863

24,339

Ozaukee

7,748

8,177

Barron

8,104

22,602

Pepin

8,268

24,992

Niobrara

Bayfield

9,003

25,622

Pierce

9,799

25,801

Park

8,863

24,339

Brown

7,748

22,230

Polk

9,799

25,801

Platte

8,863

24,339

Buffalo

7,925

22,747

Portage

9,019

25,476

Sheridan

8,863

24,339

Burnett

9,003

25,622

Price

8,104

22,602

Sublette

8,863

24,339

Calumet

7,712

22,786

Racine

9,382

26,795

Sweetwater

8,863

24,339

Chippewa

8,268

24,992

Richland

8,246

29,125

Teton

8,863

24,339

Clark

8,104

22,602

Rock

8,344

26,080

Uinta

8,863

24,339

Columbia

8,344

26,080

Rusk

8,104

22,602

Washakie

8,863

24,339

Crawford

8,133

23,995

Sauk

8,246

29,125

Weston

8,863

24,339

Dane

7,594

25,699

2023 Average Premium Tables

-31-