Navigator Manual - 08.29.16

ASSISTER CALL LINE ID855-868-4678 University of South FloridaTo reach a Marketplace Representative morequickly for basic enrollment when working witha consumer2015-2016 Assister Help Resource Center (AHRC) Re-LaunchWe are pleased to announce the re-launch of the Assister Help Resource Center,The Assister Help Resource Center (AHRC) is a dedicated call center for Navigatinformation and solutions for resolving complex application and enrollment issuesnon-Navigators such as Enrollment application program (EAP) assisters and In-pCertified application counselor (CAC) may encounter while helping consumers enthrough the Marketplaces.Navigators can access the AHRC by calling 1-855-811-7299 starting, Monday, NoAHRC is open Monday through Friday from 9am to 9pm EST and Saturday from9Open Enrollment for the individual market. Upon reaching the AHRC, an assisterThis one is for more complex problems.Florida Blue (BlueCross BlueShield FL) 1-877-236-4695Florida Health Care Plans 1-800-232-0578Florida Blue Retail Office Winter Park 321-441-2020Humana Medical Plan, Inc. 1-877-720-4854United Health CareGuardian Dental 844-561-5600Joel SeguraSales ConsultantFlorida Blue Center Clermont1450 Johns Lake Rd. Clermont, FL [email protected]

8139743143 , also known as AHRC. tors. It will provide timelys that Navigators,person assister (IPA) andnroll in health coverage ovember 2, 2015. The9am to 5pm EST during should: 1-386-676-7110 1-800-325-2028





First, the consumer should log in to his or her Marketplace account on HealthCareOnce the consumer is logged in, select his or her current application and then use the menOn the next screen, the consumer will see a list of data matching issues (called “inconsisteClick the “Verify” button by the information that needs to be uploaded.After choosing “Verify,” select a document type to upload from the list, then click on “SelecThe consumer should follow these steps for each data matching issue (or inconsistency) toUPDATED: Here are some additional tips for when consumers are uploading documReminder #1: Please don’t use the following characters in the name of the file that you upl/ \ : * ? “ < > |.Reminder #2: Not every document that consumers may want to upload is included inReminder #3: It may be necessary to submit multiple documents.Reminder #4: Each uploaded document should not be larger than 10 MB. Note: sometimeReminder #5: Each uploaded document must be a pdf, png, bmp or tiff type file.Reminder #6: If you get a red box error message, make sure you uploaded the rightReminder #7: If a document is uploaded successfully, the document will show up as subm

e.gov by clicking on “Log in” at the top of the page. nu on the left side of the screen to click on Application Details. encies” on the screen) in his or her application, if applicable. ct file to upload.” o upload the documents needed to fix the issue. If the consumer’s application haments: load: n the drop-down menu of “Document Types” viewable after clicking Verify ies it helps to submit smaller documents to process the upload. type of document (e.g., PDF not Excel file).mitted





Terms and Definitions



Removing a Household Member” Technical Assistance: Florida Blue OnlyNew VocabularyAccumulator: a health insurance industry term referring to expenses paid towards deductible andmax-out-of-pocket costs.Manual Seed: Manually entering information from one insurance plan to a new one.Product Family: Type of insurance product, i.e. PPO, HMO, EPO.Technical Assistance: When a household member is removed from a family health insurance policy andbegins their own plan, the health insurance carrier should be contacted and informed to manually seed theexpenses paid towards deductible and max-out-of-pocket, or accumulators, from the family plan to the newpolicy for the removed household member.*If* the family member removed transitions to a new policy in the same insurance product family, theaccumulators for that specific household member can be transitioned to the new single person policy. Theywill then be debited from the family policy.Example: Johnny ages off of his parents Marketplace Florida Blue plan July 31st, and purchases a new policyfor himself effective August 1st 2016. Johnny and his mother call Florida Blue and ask them to debit theexpenses paid into the deductible and Max Out of Pocket from the household policy and credit thoseexpenses towards Johnny’s new Florida Blue policy. The expenses will be debited from those paid towards thefamily Max Out of Pocket, as Johnny is no longer on the family plan. Deductible and Max Out of Pocket costsare applied to Johnny’s new policy for August through December 2016. The household plan is an HMO andJohnny’s new policy is an HMO.



ACA and Taxes



Health Coverage Exemptions Taxpayer will have a letter with ECNBased on Instructions for Form 8965, dated 12/15/151. Granted by the Marketplace – Report in Part I2. Income below filing threshold – Claim in Part IIa. Household Income (HHI) below filing threshold – Line 7aHHI = AGI + tax-exempt interest + excluded foreign income (Also called MAGI for exemptions and SRP)Include income for dependents required to fileb. Gross income below filing threshold – Line 7b Do not include losses or dependent income3. Resident of a state that did not expand Medicaid – Claim in Part III, Code G whole year Person resided in Florida (or other non-expansion state) at least one day in 2015AND HHI + nontaxable Social Security benefits is below 138% FPL4. Specific circumstances exemptions – Claim in Part III- Person born, adopted or died during 2015 – Code H for months not in family if can’t check full-year box NEW- Short coverage gap – Code B One gap of 1-2 consecutive months. Looks back to 2014.- Incarceration (after disposition of charges) – Code F for months incarcerated5. General characteristics exemptions – Claim in Part III- Citizens living abroad and certain noncitizens – Code C Includes persons not lawfully present- Member of a:Health care sharing ministry – Code DFederally recognized Indian tribe or eligible for Indian health services – Code EReligious sect opposed to insurance – Granted by Marketplace only. Refer to Navigator. Report in Part I with “Pending” in ECN column.6. General hardship exemption – Granted by Marketplace only. Refer to Navigator.Report in Part I with “Pending” in ECN column Before 2015? See HealthCare.gov exemptions screener• Homeless, evicted, or foreclosure; victim of domestic violence• Utility shut-off, unpaid medical bills, or bankruptcy; death of a close family member• Fire, flood or other disaster that substantially damaged property• Unexpected increased expenses due to caring for ill, aged, disabled family member• Dependent child is not eligible for Medicaid/KidCare and another person is required to provide coverage• Non-Marketplace coverage cancelled and you consider other plans unaffordable• Successfully appealed an eligibility decision, for months without coverage during appeals process7. Coverage considered unaffordable – Claim in Part III, Code A Unaffordable = more than 8.05% of HHI + any health premiums paid pre-tax (through salary reduction)- Person had no offer of employer coverage (as an employee or as family member of an employee) Lowest-cost Marketplace plan (including PTC) was unaffordable Use tax tools at HealthCare.gov- Person had an offer of employer coverage 1. As an employee – Lowest-cost self-only plan was unaffordable 2. No offer as employee but eligible as family member of employee – Lowest-cost family plan unaffordable8. Aggregate self-only coverage considered unaffordable – Claim in Part III, Code G Unaffordable = more than 8.05% of HHI + any health premiums paid pre-tax (through salary reduction) Two or more household members had affordable offers of employer coverage as employees AND Lowest-cost family plan was unaffordable AND Total cost of lowest-cost self-only plans for employees was unaffordable exemptions for VITA 2015rev2.docx revised 2/22/2016



Questions and Answers about Health Care Information Forms for Individuals(Forms 1095-A, 1095-B, and 1095-C)EspañolBecause of the health care law, you might receive some new forms this winter providing you with information about the healthcoverage you had or were offered in 2015. The information below is intended to help individuals understand these newforms, including who should expect to receive them and what to do with them.The Basics1. Will I receive any new health care tax forms in 2016 to help me complete my tax return?Starting early in 2016, you may receive one or more forms providing information about the health care coverage that you hador were offered during the previous year. Much like Form W-2 and Form 1099, which include information about the incomeyou received, these new health care forms provide information that you may need when you file your individual income taxreturn. Also like Forms W-2 and 1099, these new forms will be provided to the IRS by the entity that provides the form to you.The new forms are: Form 1095-A, Health Insurance Marketplace Statement. The Health Insurance Marketplace (Marketplace) sends this form to individuals who enrolled in coverage there, with information about the coverage, who was covered, and when. Form 1095-B, Health Coverage. Health insurance providers (for example, health insurance companies) send this form to individuals they cover, with information about who was covered and when. Form 1095-C, Employer-Provided Health Insurance Offer and Coverage. Certain employers send this form to certain employees, with information about what coverage the employer offered. Employers that offer health coverage referred to as “self-insured coverage” send this form to individuals they cover, with information about who was covered and when.2. When will I receive these health care tax forms?The deadline for the Marketplace to provide Form 1095-A is February 1, 2016. The deadline for insurers, other coverageproviders and certain employers to provide Forms 1095-B and 1095-C has been extended to March 31, 2016. Individualtaxpayers will generally not be affected by this extension and should file their returns as they normally would.3. Must I wait to file until I receive these forms?If you are expecting to receive a Form 1095-A, you should wait to file your 2015 income tax return until you receive thatform. However, it is not necessary to wait for Forms 1095-B or 1095-C in order to file.Some taxpayers may not receive a Form 1095-B or Form 1095-C by the time they are ready to file their 2015 tax return.While the information on these forms may assist in preparing a return, they are not required. Individual taxpayers willgenerally not be affected by this extension and should file their returns as they normally would.Like last year, taxpayers can prepare and file their returns using other information about their health insurance. You shouldnot attach any of these forms to your tax return.

4. What are the health care tax forms that I might receive and how do I use them?Health Care Form Sent To Sent By What to do with this formForm 1095-A, Health This form provides information about yourInsurance Marketplace Individuals who Marketplace Marketplace coverage.Statement enrolled in Use Form 1095-A to completeForm 8962 and reconcile advance payments of thepremium tax health credit or claim the premium tax credit on your tax return. coverage for Use Form 1095-A for information on whether themselves or you and your family members had coverage that satisfies theindividual shared responsibility their family provision. members If Form 1095-A shows coverage for you and everyone in your family for the entire year, through the check the full-year coverage box on your tax return. Marketplace If there are months when you or your family members did not have coverage, determine if you qualify for an exemption or must make an individual shared responsibility payment. Do not attach Form 1095-A to your tax return – keep it with your tax records.Form 1095-B, Health Individuals who Health Coverage This form provides information about your healthCoverage had health Providers – coverage. coverage for themselves or Insurance companies their family outside the Use Form 1095-B for information on whether members that Marketplace you and your family members had health is not reported on Form Government agencies coverage that satisfies the individual shared 1095-A or Form such as Medicare or responsibility provision. 1095-C. CHIP Employers who If Form 1095-B shows coverage for you and provide certain kinds of everyone in your family for the entire year, health coverage check the full-year coverage box on your tax (sometimes referred to return. as “self-insured coverage”) but are not If there are months when you or your family required to send Form members did not have coverage, determine if 1095-C (see below). you qualify for an exemption or must make Other coverage an individual shared responsibility payment. providers Do not attach Form 1095-B to your tax return - keep it with your tax records.

Form 1095-C, Certain Applicable large Form 1095-C provides information about theEmployer-Provided Health health coverage offered by your employer and,Insurance Offer and employees of employers– generally in some cases, about whether you enrolled inCoverage this coverage. applicable largethose with 50 or more Use Form 1095-C to help determine your employers (Seefull-time employees, eligibility for thepremium tax credit. next column). including full-time equivalent employees If you enrolled in a health plan in the Marketplace, you may need the information in Part II of Form 1095-C to help determine your eligibility for the premium tax credit. If you did not enroll in a health plan in the Marketplace, the information in Part II of your Form 1095-C is not relevant to you. Use Form 1095-C for information on whether you or any family members enrolled in certain kinds of coverage offered by your employer (sometimes referred to as “self-insured coverage”). If Form 1095-C shows coverage for you and everyone in your family for the entire year, check the full-year coverage box on your tax return. If there are months when you or your family members did not have coverage, determine if you qualify for an exemption or must make an individual shared responsibility payment. Do not attach Form 1095-C to your tax return - keep it with your tax records.5. How will I receive these forms?The Marketplace, health coverage providers and applicable large employers will mail (or hand deliver) these forms to you orprovide them electronically to you, if you have consented to electronic delivery.6. My employer or health coverage provider has suggested that I opt to receive these forms electronically ratherthan on paper. Are they allowed to ask me that?Yes. Employers and health coverage providers may ask for your consent to receive the forms electronically. This is entirelyacceptable and may be more convenient for you. Electronic forms provide the same information that is provided in the paperforms.

7. Will I get at least one form?Maybe. If you were enrolled in health coverage for 2015, you should receive a Form 1095-A, 1095-B, or 1095-C. In addition,if you were an employee of an employer that was an applicable large employer in 2015, you may receive a Form 1095-C. Ifyou don’t fall in either of these categories, you won’t receive a form.8. Will I get more than one form?Maybe. You are likely to get more than one form if you had coverage from more than one coverage provider or if you workedfor more than one employer that offered coverage. You are also likely to get more than one form if you changed coverage oremployers during the year or if different members of your family received coverage from different coverage providers.The following examples illustrate when you may get more than one Form 1095 and what to do with the information on thoseforms.Example 1: You are single with two dependent children. At the beginning of 2015, you were unemployed, and you and yourchildren were enrolled in coverage through the Marketplace. You received the benefit of advance payments of the premiumtax credit to help pay for your coverage. In August of 2015, you started working 40 hours per week for an employer with 300employees (an applicable large employer) that offered health insurance coverage to you and your children. However, thatoffer of coverage was considered unaffordable to you for purposes of the premium tax credit, so you did not enroll in it andinstead continued your Marketplace coverage with advance payments of the premium tax credit. Early in 2016, you receiveForm 1095-A (from the Marketplace) and Form 1095-C (from your employer).When you complete Form 8962, Premium Tax Credit, you will use the information on Form 1095-A to reconcile advancepayments of the premium tax credit and to verify that you had health coverage for the entire year. You will use Form 1095-Cto verify that your employer coverage was unaffordable for you. You will not attach Form 1095-A or 1095-C to your return, butyou should keep these forms with your tax records.Example 2: You are single with no dependents. At the beginning of 2015, you were employed by employer A, which has 20employees (and therefore is not an applicable large employer). You had coverage through A’s employer-sponsored plan,which is insurance that A purchases from health insurance issuer Q (i.e., not a “self-insured plan”). In June of 2015, youchanged jobs and started working 40 hours per week for employer B, which has 500 employees (and so is an applicablelarge employer). You immediately began receiving coverage through that employer’s plan, which is insurance it purchasesfrom insurance issuer R. Early in 2016, both insurance companies will send you a Form 1095-B providing information aboutthe coverage in which you were enrolled. You also will receive a Form 1095-C from employer B, the applicable largeemployer, providing information about the health coverage B offered you.You will use the information on Forms 1095-B to verify that you had health coverage for each month during the year and willcheck the full-year coverage box on your tax return. You will not need to use Form 1095-C to help complete your returnbecause the information about the offer of health coverage made by your employer relates to whether you are eligible for thepremium tax credit and you cannot get a premium tax credit if you were not enrolled in a health plan in the Marketplace. Youwill not attach Form 1095-B or Form 1095-C to your tax return, but you should keep both forms with your tax records.9. Will I get a Form 1095-C from each of my employers?Not necessarily. You will only receive a Form 1095-C from your employer if that employer is an applicable large employer,meaning it had 50 or more full-time employees (including full-time equivalent employees) in the year before the year to whichthe form relates. Most employers have fewer than 50 employees and therefore are not applicable large employers required toprovide Form 1095-C to their full-time employees.Even if your employer is an applicable large employer, you will only receive a Form 1095-C for that employer if you were a

full-time employee for that employer for at least one month of the year or if you are enrolled in an applicable large employer’sself-insured health plan, even if you are a part-time employee.10. How are the forms similar? They all provide information about your health coverage during the prior year. They are all used to determine if you, your spouse and your dependents had health coverage for the entire year and if not, for which months you did have coverage. (The Form 1095-C includes this information only if your employer is an applicable large employer and the coverage you enrolled in was a certain kind of coverage referred to as “self-insured coverage”). None of these forms should be filed with your tax return; they should be kept for your records with your other tax documents.11. How are the forms different? The forms are provided by different entities. Form 1095-A, Health Insurance Marketplace Statement, is provided by the Marketplace to individuals who enrolled or who have enrolled a family member in health coverage through the Marketplace. Form 1095-B, Health Coverage, is provided by insurance companies and other coverage providers. However, if your coverage was insurance purchased through the Marketplace or was a type of coverage referred to as “self-insured coverage” that was provided by an applicable large employer, you will receive a different form. Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, is issued by applicable large employers to their full-time employees and, in some cases, to other employees. The forms are provided to different groups of people. Form 1095-A - Only individuals who enroll in coverage through the Marketplace will get this form. Form 1095-B – Individuals who have health coverage outside of the Marketplace will get this form (except for employees of applicable large employers that provide self-insured coverage, who will receive Form 1095-C instead). Form 1095-C - Individuals who work full-time for applicable large employers will get this form. Also, part-time employees also will get this form if they enroll in self-insured coverage provided by an applicable large employer. The forms contain some different information. Form 1095-A, Form 1095-B, and some Forms 1095-C show who in your family enrolled in health coverage and for what months. Form 1095-A also provides premium information and other information you will need to reconcile advance payments of premium tax credit and claim the premium tax credit on Form 8962. And Form 1095-C shows coverage that your employer offered to you even if you chose not to take that coverage.12. What do I need to do with these forms? You will use the information on these forms to verify that you, your spouse and any dependents had coverage for each month during the year.

Like last year, if you and your family members had minimum essential coverage for every month of the year, you will check a box on your return to report that coverage. If you or any family members did not have coverage for the entire year, a coverage exemption may apply for the months without coverage. If you or any family members did not have coverage or an exemption, you may have to make an individual shared responsibility payment. If you or anyone in your family receives a Form 1095-A from the Marketplace, you will use the information on the form to complete a Form 8962 to reconcile any advance payments of the premium tax credit or to claim the premium tax credit. Do not file these forms with your tax return. Keep them in your records with your other important tax documents.13. What should I do if: I have a question about the form I received, I think I should have gotten a form but did not get it, I need a replacement form, or I believe the form I received has an error?In any of these situations, you should contact the provider of the form (or the entity that you think should have provided you aform, if you think you should have gotten a form but did not get it): For questions about the Form 1095-A, contact the Marketplace. For questions about the Form 1095-B, contact the coverage provider (see line 18 of the Form 1095-B for a contact telephone number). For questions about the Form 1095-C, contact your employer (see line 10 of Form 1095-C for a contact telephone number).How the Forms Relate to Your Tax Return14. Can I file my tax return if I have not received any or all of these forms?If you enrolled in coverage through the Marketplace you will need the information on Form 1095-A to complete Form 8962 toreconcile any advance payments of the premium tax credit or claim the premium tax credit, and to file a complete andaccurate tax return. If you need a copy of your Form 1095-A, you should go to HealthCare.gov or your state Marketplacewebsite and log into your Marketplace account, or call your Marketplace call center. Although information from the Form1095-C – information about an offer of employer provided coverage - can assist you in determining eligibility for the premiumtax credit, it is not necessary to have Form 1095-C to file your return. See Publication 974 for additional information onclaiming the premium tax credit.You do not have to wait for either Form 1095-B or 1095-C from your coverage provider or employer to file your individualincome tax return. You can use other forms of documentation, in lieu of the Form 1095 information returns to prepare yourtax return. Other forms of documentation that would provide proof of your insurance coverage include: insurance cards, explanation of benefits statements from your insurer, W-2 or payroll statements reflecting health insurance deductions,

records of advance payments of the premium tax credit and other statements indicating that you, or a member of your family, had health care coverage.If you and your entire family were covered for the entire year, you may check the full-year coverage box on your return. Ifyou or your family members did not have coverage for one or more months of the calendar year, you may claim anexemption or make an individual shared responsibility payment.You will not need to send the IRS proof of your health coverage. However, you should keep any documentation with yourother tax records. This includes records of your family’s employer-provided coverage, premiums paid, and type of coverage.15. Am I required to file a tax return if I receive one of these forms?If you receive a Form 1095-A, Health Insurance Marketplace Statement, showing that advance payments of the premium taxcredit were paid for coverage for you or your family member, you generally must file an individual income tax return andsubmit a Form 8962 to reconcile those advance payments, even if you would not otherwise be required to file a tax return.You also must file an individual income tax return and submit a Form 8962 to claim the premium tax credit, even if noadvance payments of the premium tax credit were made for your coverage. For more information, see the instructions toForm 8962,However, you are not required to file a tax return solely because you received a Form 1095-B or a Form 1095-C. Forexample, if you are enrolled in Medicaid you will receive a Form 1095-B. If you do not have a tax filing requirement, you donot have to file a tax return solely because you received the Form 1095-B reflecting your Medicaid coverage.The health care law tax filing requirements are the same as last year. If you enrolled in coverage through the Marketplace, you must file a tax return and reconcile any advance payments of the premium tax credit that were paid on your behalf. If you have a filing requirement and everyone in your family had coverage for the entire year, you should check the full-year coverage box on your tax return. If you or any family members did not have coverage for the entire year, you should claim any applicable coverage exemption or make an individual shared responsibility payment.16. Should I attach Form 1095-A, 1095-B or 1095-C to my tax return?No. Although you may use the information on the forms to help complete your tax return, these forms should not be attachedto your return or sent to the IRS. The issuers of the forms are required to send the information to the IRS separately. Youshould keep the forms for your records with your other important tax documents. Page Last Reviewed or Updated: 11-Jan-2016https://www.irs.gov/affordable-care-act/questions-and-answers-about-health-care-information-forms-for-individuals



Department of the Treasury For each month you must either: Internal Revenue Service ✓ Have Health CoverageInstructions for Form 8965 See the instructions for your tax return forHealth Coverage information on reporting full-year coverage.Exemptions(and instructions ORfor figuring yourshared Claim a Coverage Exemptionresponsibility on Form 8965payment) OR $ Make a Shared Responsibility Payment See Shared Responsibility Payment for information on how to figure your shared responsibility payment.Future Developments. For the latest information about devel place, complete Part I of Form 8965. If you or another member ofopments related to Form 8965 and its instructions, such as legis your tax household is claiming a coverage exemption on your taxlation enacted after they were published, go to www.irs.gov/ return, complete Part II or Part III of Form 8965. Depending onform8965. your situation, you may need to complete one or more parts of the form.What's New Shared responsibility payment. You must make a shared re sponsibility payment if, for any month, you or another member ofChanges to coverage exemptions. Several changes have your tax household didn't have health care coverage (referred tobeen made to the types of coverage exemptions available for as “minimum essential coverage”) or a coverage exemption. See2015. Some coverage exemptions have been added, clarified, Shared Responsibility Payment, later, to figure your payment, ifor are no longer available. See the Types of Coverage Exemp any. Report your shared responsibility payment on your tax retions chart. turn (Form 1040, line 61; Form 1040A, line 38; or Form 1040EZ, line 11).Shared responsibility payment worksheet. A flowchart hasbeen added to help you figure your shared responsibility pay Who Must Filement. See To Figure Your Shared Responsibility Payment. File Form 8965 to report or claim a coverage exemption if:General Instructions You are filing a Form 1040, 1040A, or 1040EZ (even if youPurpose of Form are filing it because you are a dual status alien for your first year of U.S. residency or a nonresident or dual status alien who elecIndividuals must have health care coverage, have a health cov ted to file a joint return with a U.S. spouse),erage exemption, or make a shared responsibility payment withtheir tax return. Use Form 8965 to report a coverage exemption You can't be claimed as a dependent by another taxpayer,granted by the Marketplace (also called the “Exchange”) or to You or anyone else in your tax household didn't have miniclaim a coverage exemption on your tax return. In addition, use mum essential coverage for each month of 2015, andthese instructions to figure your shared responsibility payment if You want to report or claim a coverage exemption for yourfor any month you or another member of your tax household (de self or another member of your tax household.fined later) had neither health care coverage nor a coverage ex Attach Form 8965 to your tax return (Form 1040, Form 1040A, oremption. Form 1040EZ). Reminder: If you need health coverage, visit TIP Form 8965 is used only to claim and report coveragewww.HealthCare.gov to learn about health insurance options exemptions. Don't use it to report minimum essentialthat are available for you and your family, how to purchase coverage even if you are unable to check thehealth insurance, and how you might qualify to get financial as Full-year coverage box on your tax return.sistance with the cost of insurance. Not required to file a tax return. If you aren't required to file aCoverage exemptions. If you or another member of your tax tax return, your tax household is exempt from the shared responhousehold was granted a coverage exemption from the Market sibility payment and you don't need to file a tax return to claim the coverage exemption. However, if you aren't required to file a tax return but choose to file anyway, you must claim theDec 15, 2015 -1- Cat. No. 60810G

coverage exemption on line 7a or 7b of Form 8965. (See the in a member of your tax household for any month had coverage forstructions under Part II, later.) all the months they were members of your tax household, check the Full year coverage checkbox on your return. For informationForm 1040NR and Form 1040NR-EZ filers. If you file a Form on how to identify months during which an individual was not a1040NR or Form 1040NR EZ (including a dual status tax return member of your tax household for one of these reasons, seefor your last year of U.S. residency) or you are claimed as a per Member of tax household born, adopted, or died in Part III, later.sonal exemption on a Form 1040NR or Form 1040NR EZ, you You don't need to file Form 8965 solely to identify these months.are exempt from the shared responsibility payment. Don't attachForm 8965 to your Form 1040NR or Form 1040NR EZ. Dependents of more than one taxpayer. Your tax house hold doesn't include someone you can, but don't, claim as a de For more information see chapters 1 and 6 of Pub. 519. pendent if the dependent is properly claimed on another taxpay er's return or can be claimed by a taxpayer with higher priority ! Only one Form 8965 should be filed for each tax under the tie breaker rules described in Pub. 501. household. If you can be claimed as a dependent byCAUTION another taxpayer, you don't need to file Form 8965 Household income. You will need to calculate your household and don't owe a shared responsibility payment. income:More Information To determine if you can claim the coverage exemption for individuals with household income below the filing threshold,For more information on coverage exemptions, the shared responsibility payment, and other terms discussed in these instruc To determine if you can claim the exemption for coveragetions, including answers to frequently asked questions and links that is considered unaffordable, andto the final regulations issued by the Treasury Department andIRS, go to www.irs.gov/uac/Individual-Shared-Responsibility- To figure your shared responsibility payment if you don'tProvision. have minimum essential coverage or qualify for a coverage ex emption.Types of Coverage Exemptions For purposes of Form 8965, your household income is yourThe Types of Coverage Exemptions chart shows the types of modified adjusted gross income (MAGI) plus the MAGI of eachcoverage exemptions available and whether the coverage ex individual in your tax household whom you claim as a dependentemption may be granted by the Marketplace, claimed on your if that individual is required to file a tax return because his or hertax return, or both. If you are claiming a coverage exemption in income meets the income tax return filing threshold. Use the FilPart III, the right hand column of the chart shows which code you ing Requirements for Children and Other Dependents chart toshould enter in column (c) to claim that particular coverage ex determine whether your dependent is required to file his or heremption. own tax return.TIP If you are eligible for a coverage exemption for 2015 Modified adjusted gross income (MAGI). For purposes of that can be claimed on the tax return, claim it in Part Form 8965, your MAGI is your adjusted gross income plus cer II or Part III even if it can be granted by the Market- tain other items from your tax return. place. If you file Form 1040. If you file Form 1040, figure your If the coverage exemption can be granted only by the Market- MAGI by adding the amounts reported on Form 1040, lines 8bplace (for example, a coverage exemption based on member- and 37. If you claimed the foreign earned income exclusion,ship in certain religious sects or certain hardship exemptions), housing exclusion, or housing deduction, add the amounts fromapply to the Marketplace for that coverage exemption before fil- Form 2555, lines 45 and 50, or Form 2555 EZ, line 18. If youring your tax return. If the Marketplace hasn't processed your ap- dependent has a filing requirement, but you elect to report theplication before you file your tax return, complete Part I and enter dependent's income on Form 8814, include the dependent's“pending” in column (c) for each individual listed. MAGI in the household income by adding Form 8814, line 1b and the smaller of Form 8814, line 4 or 5.Definitions If you file Form 1040A. If you file Form 1040A, figure yourTax household. For purposes of Form 8965, your tax house MAGI by adding the amounts on Form 1040A, lines 8b and 21.hold generally includes you, your spouse (if filing a joint return),and any individual you claim as a dependent on your tax return. If you file Form 1040EZ. If you file Form 1040EZ, figureIt also generally includes each individual you can, but don't, your MAGI by adding the amount on Form 1040EZ, line 4 andclaim as a dependent on your tax return. To find out if you can any tax exempt interest reported in the space to the left of line 2.claim someone as your dependent, see Exemptions for Depend-ents in Pub. 501, Exemptions, Standard Deduction, and Filing TIP You can use Step 3 under Shared ResponsibilityInformation, or Line 6c—Dependents in the instructions for Form Payment, later, to figure your household income.1040 or Form 1040A. Marketplace. A Marketplace, or Health Insurance Marketplace Birth, death, or adoption. An individual is included in your (also referred to as an “Exchange”), is a governmental agency ortax household in a month only if he or she is alive for the full nonprofit entity that makes qualified health plans available to inmonth. Also, if you adopt a child during the year, the child is in dividuals and grants certain coverage exemptions. The termcluded in your tax household only for the full months that followthe month in which the adoption occurs. If each individual who is -2-

Types of Coverage ExemptionsThis chart shows all of the coverage exemptions available for 2015, including information about where the coverage exemptions canbe obtained and the code for the coverage exemption that is to be used on Form 8965 when you claim the exemption. If your coverageexemption was granted by the Marketplace, you will need to enter the Exemption Certificate Number (ECN) provided by the Marketplace (see the instructions for Part I). Coverage Exemption Granted by Claimed on Code for Marketplace tax return ExemptionIncome below the filing threshold—Your gross income or your household income was lessthan your applicable minimum threshold for filing a tax return. No CodeCoverage considered unaffordable—The minimum amount you would have paid for See Part IIpremiums is more than 8.05% of your household income.Short coverage gap—You went without coverage for less than 3 consecutive months during Athe year. BCitizens living abroad and certain noncitizens—You were: C A U.S. citizen or a resident alien who was physically present in a foreign country orcountries for at least 330 full days during any period of 12 consecutive months; D E A U.S. citizen who was a bona fide resident of a foreign country or countries for an Funinterrupted period that includes an entire tax year; G G A bona fide resident of a U.S. territory; H A resident alien who was a citizen or national of a foreign country with which the U.S. Need ECNhas an income tax treaty with a nondiscrimination clause, and you were a bona fide resident See Part Iof a foreign country for an uninterrupted period that includes an entire tax year; Need ECN Not lawfully present in the U.S and not a U.S. citizen or U.S. national. For more See Part Iinformation about who is treated as lawfully present in the U.S. for purposes of this coverage Need ECNexemption, visit www.HealthCare.gov; or See Part I A nonresident alien, including (1) a dual status alien in the first year of U.S. residency Need ECNand (2) a nonresident alien or dual status alien who elects to file a joint return with a U.S. See Part Ispouse. This exemption doesn't apply if you are a nonresident alien for 2015, but met certain Need ECNpresence requirements and elected to be treated as a resident alien. For more information See Part Isee Pub. 519. Need ECNMembers of a health care sharing ministry—You were a member of a health care sharing See Part Iministry.Members of Indian tribes—You were either a member of a Federally recognized Indiantribe, including an Alaska Native Claims Settlement Act (ANCSA) Corporation Shareholder(regional or village), or you were otherwise eligible for services through an Indian health careprovider or the Indian Health Service.Incarceration—You were in a jail, prison, or similar penal institution or correctional facilityafter the disposition of charges.Aggregate self-only coverage considered unaffordable—Two or more family members'aggregate cost of self only employer sponsored coverage was more than 8.05% ofhousehold income, as was the cost of any available employer sponsored coverage for theentire family.Resident of a state that did not expand Medicaid—Your household income was below138% of the federal poverty line for your family size and at any time in 2015 you resided in astate that didn't participate in the Medicaid expansion under the Affordable Care Act.Member of tax household born, adopted, or died—During 2015 a child was added to yourtax household by birth or adoption, or a member of your tax household died during the year,and you can't check the full year coverage checkbox on your tax return.Members of certain religious sects—You are a member of a recognized religious sect.Determined ineligible for Medicaid in a state that didn't expand Medicaid coverage—You were determined ineligible for Medicaid solely because the state in which you resideddidn't participate in Medicaid expansion under the Affordable Care Act.General hardship—You experienced a hardship that prevented you from obtaining coverageunder a qualified health plan.Coverage considered unaffordable based on projected income—You didn't haveaccess to coverage that is considered affordable based on your projected household income.Unable to renew existing coverage—You were notified that your health insurance policywas not renewable and you considered the other plans available to be unaffordable.Certain Medicaid programs that are not minimum essential coverage—You were (1)enrolled in Medicaid coverage provided to a pregnant woman that is not recognized asminimum essential coverage; (2) enrolled in Medicaid coverage provided to a medicallyneedy individual (also known as Spend down Medicaid or Share of Cost Medicaid) that is notrecognized as minimum essential coverage; or (3) enrolled in Medicaid, and receivedminimum essential coverage for one or more months of the year by meeting a spend down,but not in other months because the spend down had not been met.“Marketplace” refers to state Marketplaces, regional Marketpla Minimum essential coverage. Minimum essential coverage isces, subsidiary Marketplaces, and the Federally facilitated Mar health coverage that satisfies the requirement for individuals toketplace. -3-

have health coverage. Minimum essential coverage generally in Timing. You are considered to have minimum essential covcludes coverage under a government sponsored program, cov erage for a month if you have it for at least 1 day during thaterage from your employer, and coverage under certain plans month. For example, if you start a new job on June 26 and arethat you buy in the individual market. If you, or a member of your covered under your employer’s plan starting on that day, you arefamily, had minimum essential coverage in 2015, the entity that treated as having coverage for the entire month of June.provided the coverage may have sent you a Form 1095 A,1095 B, or 1095 C, that lists individuals in your family who were Foreign coverage. In general, coverage provided by a forenrolled in minimum essential coverage and shows their months eign employer to its employees and related individuals is miniof coverage. Individuals enrolled in a qualified health plan mum essential coverage. Individuals with such coverage shouldthrough the Marketplace generally receive this information on see Pub. 974, Premium Tax Credit (PTC). However, coverageForm 1095 A, Health Insurance Marketplace Statement. Individ that an individual purchases directly from a foreign health insuruals enrolled in health insurance coverage outside the Market ance issuer or that is provided by the government of a foreignplace, in a government sponsored program, or in certain other country doesn't qualify as minimum essential coverage unlesscoverage generally receive this information on Form 1095 B, it's recognized as minimum essential coverage by the DepartHealth Coverage. Individuals enrolled in self insured coverage ment of Health and Human Services (HHS). To find out if HHSfrom an employer generally receive Form 1095 C, Employ has recognized particular forms of foreign coverage as minimumer Provided Health Insurance Offer and Coverage. For more in essential coverage, go to www.cms.gov/CCIIO/Programs-and-formation on these forms, see the instructions for Form 1040, Initiatives/Health-Insurance-Market-Reforms/minimum-line 61; Form 1040A, line 38; or Form 1040EZ, line 11. The essential-coverage.html, and scroll down and click on the link forTypes of Minimum Essential Coverage chart provides more in the list of approved plans.formation about the plans and arrangements that are minimumessential coverage. Coverage for business owners. Minimum essential cover age includes coverage provided to a business owner (such as aFiling Requirements for Children and Other DependentsUse this chart to help you determine if a dependent you claimed on your return must file his or her own tax return. If the dependentis required to file a tax return because his or her income meets the filing threshold the dependent's MAGI must be included inhousehold income for purposes of Form 8965, even if you elect to report that dependent's income on Form 8814. Do not include adependent's MAGI in household income if the dependent's income is below the filing threshold, even if he or she chooses to file areturn for another reason. In this chart, unearned income includes taxable interest, ordinary dividends, and capital gain distributions. It also includes TIP unemployment compensation, taxable social security benefits, pensions, annuities, and distributions of unearned income from a trust. Earned income includes salaries, wages, tips, professional fees, and taxable scholarship and fellowship grants. Gross income is the total of your unearned and earned income. Single dependents. Was your dependent either age 65 or older or blind? No. Your dependent must file a return if any of the following apply. His or her unearned income was over $1,050. His or her earned income was over $6,300. His or her gross income was more than the larger of— $1,050, or His or her earned income (up to $5,950) plus $350. Yes. Your dependent must file a return if any of the following apply. His or her unearned income was over $2,600 ($4,150 if 65 or older and blind). His or her earned income was over $7,850 ($9,400 if 65 or older and blind). His or her gross income was more than the larger of— $2,600 ($4,150 if 65 or older and blind), or His or her earned income (up to $5,950) plus $1,900 ($3,450 if 65 or older and blind). Married dependents. Was your dependent either age 65 or older or blind? No.Your dependent must file a return if any of the following apply. His or her unearned income was over $1,050. His or her earned income was over $6,300. His or her gross income was at least $5 and his or her spouse files a separate return and itemizes deductions. His or her gross income was more than the larger of— $1,050, or His or her earned income (up to $5,950) plus $350. Yes. Your dependent must file a return if any of the following apply. His or her unearned income was over $2,300 ($3,550 if 65 or older and blind). His or her earned income was over $7,550 ($8,800 if 65 or older and blind). His or her gross income was at least $5 and his or her spouse files a separate return and itemizes deductions. His or her gross income was more than the larger of— $2,300 ($3,550 if 65 or older and blind), or His or her earned income (up to $5,950) plus $1,600 ($2,850 if 65 or older and blind). -4-

Types of Minimum Essential CoverageMinimum essential coverage means health care coverage under any of the following programs. It does not, however, include coverage consisting solely of excepted benefits. Excepted benefits include stand alone vision and dental plans (except pediatric dental coverage), workers' compensation coverage, and coverage limited to a specified disease or illness. Employer-sponsored coverage: Group health insurance coverage for employees under— A governmental plan, such as the Federal Employees Health Benefit program A plan or coverage offered in the small or large group market within a state A grandfathered health plan offered in a group market A self insured health plan for employees COBRA coverage Retiree coverage Coverage under an expatriate health plan for employees Individual health coverage: Health insurance you purchase directly from an insurance company Health insurance you purchase through the Marketplace Health insurance provided through a student health plan Catastrophic plans Coverage under an expatriate health plan for non employees such as students and missionaries Coverage under government-sponsored programs: Medicare Part A coverage Medicare Advantage plans Most Medicaid coverage* Children's Health Insurance Program (CHIP) coverage Most types of TRICARE coverage Comprehensive health care programs offered by the Department of Veterans Affairs Health coverage provided to Peace Corps volunteers Department of Defense Nonappropriated Fund Health Benefits Program Refugee Medical Assistance Coverage through a Basic Health Program (BHP) standard health plan Other coverage: Certain foreign coverage Certain coverage for business owners Coverage recognized by HHS as minimum essential coverage.** *Medicaid programs that provide limited benefits generally don't qualify as minimum essential coverage; however, HHS will provide a hardship exemption to individuals with certain types of limited benefit Medicaid coverage. **Plans recognized as minimum essential coverage are listed at: www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/minimum-essential- coverage.html, scroll down and click on the link for the list of approved plans.partner or sole proprietor) under a plan that is eligible employ than one coverage exemption from the Marketplace, complete aer sponsored coverage with respect to at least one employee. separate line for each coverage exemption for that individual. If you need more space, attach a separate statement showing theSpecific Instructions information required in columns (a) through (c) for each addition al coverage exemption.Part I — Marketplace-Granted CoverageExemptions for Individuals Coverage exemptions that apply to multiple years. If you were granted a coverage exemption that applies for multipleIf you or another member of your tax household has been gran years, you must report the coverage exemption on Form 8965ted one or more coverage exemptions from the Marketplace, or every year it applies. See Duration under Members of certain re-has an application for a coverage exemption pending with the ligious sects and Members of Indian tribes, later.Marketplace, complete Part I to report these exemptions. Complete a line for each individual who was granted or has a pending Lines 1–6application for a Marketplace granted coverage exemption. If anindividual was granted or has a pending application for more Column (a)—Name of Individual Enter the name of each person in your tax household who was granted a coverage exemption from the Marketplace or has an application for a coverage exemption pending with the Market -5-

place. If the individual is listed on page 1 of your tax return, enter Part II — Coverage Exemptions Claimed on Yourthe name exactly as it appears on your tax return. Return for Your HouseholdColumn (b)—Social Security Number (SSN) Use Part II to claim a coverage exemption on behalf of your taxEnter the SSN of the individual listed in column (a). If the individ household because your household income or your gross inual is listed on page 1 of your tax return, the SSN in this column come is less than your filing threshold. See Filing Thresholds Forshould match the individual’s SSN listed on your tax return. Most People, later, to figure your filing threshold.Column (c)—Exemption Certificate Number (ECN) If you aren't required to file a tax return and don'tEnter the ECN that you received from the Marketplace for the in TIP wish to file a return, your tax household is exemptdividual listed in column (a). If you were granted a coverage exemption from the Marketplace, but didn't receive an ECN, or from the shared responsibility payment and you don'tdon't know your ECN, contact the Marketplace to obtain your need to file a return or do anything else to claim theECN. If the Marketplace hasn't processed your application be coverage exemption. If your gross income is less than your filingfore you file, enter “pending.” threshold but you file a tax return for any reason, see the instruc- tions for lines 7a and 7b next.Members of certain religious sects (enter ECN). An individual may claim a coverage exemption for members of recognized Line 7a—Household Income Below Filingreligious sects only if the Marketplace has granted the individual Thresholdan exemption. A recognized religious sect is a religious sect inexistence since December 31, 1950, that is recognized by the You can claim a coverage exemption if your household incomeSocial Security Administration as conscientiously opposed to ac is less than your filing threshold. To claim this coverage exempcepting any insurance benefits, including Medicare and social tion, you must first figure your household income (see House-security. hold income, under Definitions, earlier). Then compare your household income to the filing threshold that applies to you Duration. If a member of your tax household was granted a based on your filing status. If your household income is less thancoverage exemption as a member of a religious sect, you must your filing threshold, check the box labeled “Yes.”report it on Form 8965 every year it applies. Once the Marketplace grants an individual this exemption, it generally applies If you qualify for this coverage exemption, everyone in youreach year unless the individual reports to the Marketplace that tax household is exempt for the entire year. You don't need tohe or she no longer qualifies for the coverage exemption. How complete Part III.ever, for an individual granted the exemption before his or her21st birthday, the exemption applies only until the first full month Example 1. Lizzie and Fitz are both under age 65. They arefollowing the individual's 21st birthday. After that, the individual married and have three children, all of whom they claim as demust apply to the Marketplace again for the exemption. pendents on their tax return. Lizzie and Fitz file Form 1040 as married filing jointly, report $16,000 of wages, and claim theHardship exemptions. In addition to the coverage exemption earned income credit. One of their children, Charlie, receivedfor members of recognized religious sects, certain hardship ex taxable interest of $1,100. Their other two children have no inemptions also may be granted only by the Marketplace. See the come. Lizzie and Fitz were uninsured all year and do not qualifyTypes of Coverage Exemptions chart. for any other coverage exemption.Members of Indian tribes. If a member of your tax household To see if they qualify to claim the coverage exemption onwas granted a coverage exemption as a member of an Indian line 7a of Form 8965, they first calculate their household income.tribe you must report it on Form 8965 every year it applies. It ap On their Form 1040, they have no amount on line 8b andplies until the individual reports to the Marketplace that he or she $16,000 on line 37, so their MAGI is $16,000. They look at theno longer qualifies for the coverage exemption. Filing Requirements for Children and Other Dependents chart and see that since Charlie has $1,100 in unearned income, he is Members of a health care sharing ministry, members required to file his own tax return. On Charlie’s Form 1040EZ, he has no entry beside line 1b and $1,100 on line 4, so his MAGI is TIP of Federally-recognized Indian tribes, individuals eli- $1,100. Their household income is $17,100 ($1,100 of Charlie’s MAGI plus Lizzie and Fitz’s $16,000). They look at the Filing gible for services from an Indian health care provider, Thresholds For Most People chart and see that their household and incarcerated individuals may have been granted income ($17,100) is less than their filing threshold ($20,600).a coverage exemption from the Marketplace or may claim a cov- Because Lizzie and Fitz are claiming the earned income credit,erage exemption on their tax return. If you received one of these they are going to file a tax return to claim the credit, even thoughcoverage exemptions from the Marketplace, follow the instruc- they are below the filing threshold. Lizzie and Fitz check thetions for Part I to report your exemption. If you didn't receive a “Yes” box on line 7a and leave Part III blank.coverage exemption from the Marketplace and qualify to claimone of these exemptions on your tax return, see the instructions Example 2. The facts are the same as in Example 1 exceptfor Part III, later. that Charlie does not file his own tax return. Instead Lizzie and Fitz elect to report Charlie’s taxable interest on Form 8814. Be cause Charlie's only income was $1,100 of taxable interest, line 1a on Form 8814 is $1,100, line 1b is zero, line 4 is $1,100, and line 5 is $2,100. Because the amount on line 4 is less than -6-

the amount on line 5, they add it to the amount on line 1b for a Part III — Coverage Exemptions Claimed ontotal of $1,100 (zero on line 1b + $1,100 on line 4). They add the$1,100 from Form 8814 to their MAGI of $16,000 for household Your Return for Individualsincome of $17,100. Their household income is less than their filing threshold, so Lizzie and Fitz check the “Yes” box on line 7a Use Part III to claim a coverage exemption on your tax return forand leave Part III blank. yourself or another member of your tax household. Complete a line for each individual for whom you are claiming a coverage ex Example 3. The facts are the same as Example 1 except emption. If you are claiming more than one coverage exemptionthat Lizzie and Fitz are not claiming the earned income credit. for any individual, you must generally complete a separate lineThey do not need to file a tax return. They and everyone in their for each coverage exemption. But if, for any individual, you aretax household are exempt from the requirement to have mini claiming two or more different types of coverage exemptions thatmum essential coverage or make a shared responsibility pay have the same code listed in the Types of Coverage Exemptionsment and need to do nothing further to claim the coverage ex chart, use a single line to claim those coverage exemptions. Ifemption. you need more than six lines, attach an additional page showing the information required in columns (a) through (p), as applicaLine 7b—Gross Income Below Filing ble, for each additional coverage exemption.Threshold Coverage exemptions that may be granted for lessYou can claim a coverage exemption if your gross income is lessthan your filing threshold. To claim this coverage exemption, you TIP than a full tax year apply to each month in which anmust first figure your gross income. Then compare your gross income to the filing threshold that applies to you based on your fil individual was eligible for the coverage exemption foring status. See Filing Thresholds For Most People. If your gross at least one day in that month. For example, if an in-income is less than your filing threshold, check the box labeled dividual is incarcerated following the disposition of charges from“Yes.” June 28 to July 28, the individual is eligible for the coverage ex- emption for June and July. If you qualify for this coverage exemption, everyone in yourtax household is exempt for the entire year. You don't need to Lines 8–13complete Part III. Column (a)—Name of Individual Example 1. Emma and George are both under age 65. Theyare married and have one child, whom they claim as a depend Enter the name of each person in your tax household for whoment on their tax return. Emma and George file Form 1040 as mar you are claiming a coverage exemption. If the individual is listedried filing jointly, report $20,000 of wages, $3,000 of tax exempt on page 1 of your tax return, enter the name exactly as it apinterest, and claim the earned income credit. Emma and George pears on your tax return.figure their gross income as $20,000 (their wages) and theirhousehold income as $23,000 (Form 1040, line 8b plus Form Column (b)—Social Security Number (SSN)1040, line 37). Emma and George were uninsured all year anddo not qualify for any other coverage exemption. They look at Enter the SSN of the individual listed in column (a). If the individthe Filing Thresholds For Most People chart and see that their ual is listed on page 1 of your tax return, the SSN in this columnhousehold income ($23,000) is more than their filing threshold should match the individual’s SSN listed on your tax return.($20,600). IRS Individual Taxpayer Identification Number (ITIN) for Because their household income is more than their filing Aliens. If the individual listed in column (a) doesn't have andthreshold, Emma and George can’t check the “Yes” box on isn't eligible to get an SSN, enter the ITIN assigned to that perline 7a. To see if they qualify to claim the coverage exemption on son by the IRS.line 7b, they compare their gross income ($20,000) to their filingthreshold ($20,600) and see that they can check the “Yes” box Adoption Taxpayer Identification Number (ATIN). If the indion line 7b. Because Emma and George are claiming the earned vidual was placed with you for legal adoption and you don't knowincome credit, they are going to file a tax return to claim the cred his or her SSN, enter the ATIN assigned to that individual by theit, even though they are below the filing threshold. Emma and IRS.George check the “Yes” box on line 7b and leave Part III blank. No identification number. If the individual listed in column (a) Example 2. The facts are the same as Example 1 except doesn't have an SSN, ITIN, ATIN, or other identification numberthat Emma and George are not claiming the earned income from the IRS, leave column (b) blank for that individual.credit. They do not need to file a tax return. They and everyonein their tax household are exempt from the requirement to have Column (c)—Exemption Typeminimum essential coverage or make a shared responsibilitypayment and need to do nothing further to claim the coverage Use column (c) to identify the type of coverage exemption youexemption. are claiming for yourself or another member of your tax house hold. Enter the code for the appropriate coverage exemption lis ted below and in the Types of Coverage Exemptions chart. Coverage considered unaffordable (code “A”). You can claim a coverage exemption for yourself or another member of your tax household for any month in which: The individual is eligible for coverage under an employer plan and that coverage is considered unaffordable, or -7-

The individual is not eligible for coverage under an employ For whom a personal exemption deduction is claimed oner plan and the coverage available for that individual through the your tax return,Marketplace is considered unaffordable. Who is eligible for the coverage, and Coverage is considered unaffordable if the individual's re Who doesn't qualify for another coverage exemption.quired contribution (described later) is more than 8.05% of For this purpose, the amount the employee would pay includeshousehold income. amounts that may be paid through a salary reduction arrange ment. Use the Affordability Worksheet, later, to determine whetherthis coverage exemption applies to you or another member of Example 1—unmarried employee with no dependents.your tax household for one or months of the year. Joyce is unmarried and has no dependents. Her household in come is $60,000. During 2015, Joyce could purchase self only To claim this coverage exemption, enter code “A” in Part III, coverage through her employer at a total cost to her of $5,000.column (c), and identify the months to which the exemption ap As a result, Joyce can claim the exemption for unaffordable covplies as described under Columns (d) - (p)—Calendar Months, erage because her required contribution ($5,000) is more thanlater. 8.05% of her household income ($4,830, which is $60,000 multi plied by 0.0805). Required contribution. Your required contribution dependson the type of coverage you are eligible to purchase. If you or an Example 2—married employee with dependents. Susanother member of your tax household is eligible for coverage un and Lee are married and file a joint return for 2015. They haveder an employer plan, see Determining an individual's required two children, Elizabeth and Emilee, whom they claim as dependcontribution—Individuals eligible for coverage under an employ- ents on their return. During 2015, Susan could purchase self oner plan, later. If you or another member of your tax household ly coverage under a plan offered by her employer at a cost to herisn't eligible for coverage under an employer plan, see Determin- of $4,000. Susan could also purchase family coverage under theing an individual's required contribution—Individuals not eligible plan, which would cover her, Lee, Elizabeth, and Emilee, at afor coverage under an employer plan, later. cost to her of $12,000. Lee could not purchase health insurance through his employer. Their household income for 2015 is Eligibility for employer-sponsored coverage. An individ $90,000.ual is eligible for coverage under an employer plan for a month ifthe individual could have enrolled in the plan and had coverage Susan is ineligible for the exemption for unaffordable coverfor any day that month, even if the individual is eligible for anoth age for 2015 because her required contribution ($4,000) is noter type of minimum essential coverage. Individuals eligible for more than 8.05% of her household income ($7,245, which iscoverage under an employer plan for a month don't need to de $90,000 multiplied by 0.0805). If Susan does not qualify for antermine whether other coverage would be affordable for that other coverage exemption, she would make a shared responsimonth. bility payment for the months during which she did not have cov erage. Household income adjustment. For purposes of determining whether this coverage exemption applies, increase house The required contribution for Lee, Elizabeth, and Emilee ishold income by any amount that your wages or the wages of any Susan's share of the cost for family coverage ($12,000), which isother member of your tax household whose MAGI was included more than 8.05% of their household income ($7,245). As a rein your household income were reduced to pay all or a portion of sult, Lee, Elizabeth, and Emilee are eligible for the exemption forthe premiums for employer sponsored coverage (a salary reduc unaffordable coverage for 2015. Susan and Lee do not need totion arrangement). make a shared responsibility payment for the months during which Lee, Elizabeth, and Emilee did not have coverage. Determining an individual's required contribution—Individuals eligible for coverage under an employer plan. Employer-sponsored coverage for part of the year. If you or another member of your tax household becomes unem Employees eligible for self-only coverage from their em- ployed or changes employers during the year, test the affordabilployers. If you or another member of your tax household is an ity of coverage for that individual separately for each employemployee and is eligible for self only coverage through his or her ment period. Similarly, if the required contribution for any emown employer, the employee's required contribution is the ployer plan changes during the year (such as when one planamount he or she would pay for the lowest cost self only cover year ends and another one starts during the year), test the afage in which he or she can enroll. For this purpose, the amount fordability of the coverage separately for each period.the employee would pay includes an amount that may be paidthrough a salary reduction arrangement. Coverage under an employer plan is considered unaffordable for a part year period if the annualized premium for self only cov Other family members eligible for employer coverage. If erage (in the case of an employee) or family coverage (in theyou or another member of your tax household isn't eligible for case of a related individual) under the plan for the part year pericoverage through his or her own employer (if any) but is eligible od is more than 8.05% of your household income.for family coverage under a plan offered by your employer oryour spouse's employer if filing jointly (for example, a child who You can use the Annualized Premium Worksheet to figure theis eligible to enroll in family coverage offered by your employer), annualized premium.the individual's required contribution is the amount the employeewould pay for the lowest cost family coverage that would covereveryone in the tax household: -8-

Annualized Premium Worksheet quired contribution is based on the premium for the lowest cost bronze plan available through the Marketplace minus the maxi ! Complete a separate worksheet for each part-year period. mum premium tax credit that you could have claimed if the indi viduals had enrolled in this plan.CAUTION For this purpose, use the lowest cost bronze plan available1. Enter the premiums paid during the part year period through the Marketplace that covers everyone in your tax house2. Enter the number of full months in the part year period hold:3. Divide line 1 by line 24. Multiply line 3 by 12.0. This is your annualized premium for whom a personal exemption deduction is claimed on your tax return, Certain employer arrangements. An employee's requiredcontribution for employer sponsored coverage may be affected who isn't eligible for employer coverage, andby various arrangements offered by the employer. For example: who doesn't qualify for another coverage exemption. Wellness incentives: An employee's required contribution For information on the lowest cost bronze plan you couldfor employer sponsored coverage is reduced by a wellness in have purchased for your tax household, visitcentive offered by the employer only if the incentive relates ex www.HealthCare.gov/tax-tool or contact the Marketplace servingclusively to tobacco use. A wellness incentive relating exclusive your area. Subtract from the premium the maximum premium taxly to tobacco use is taken into account regardless of whether the credit that you could have claimed if these individuals had enrolemployee would have earned the incentive had he or she enrol led in that plan. You can claim the exemption for unaffordableled in the coverage. coverage for the individual if the result is more than 8.05% of your household income. Health reimbursement arrangements (HRAs): An employee's required contribution for employer sponsored coverage If the Marketplace serving the area where the individual regenerally is reduced by amounts the employer offering the cov sides doesn't offer a single bronze plan that would cover everyerage contributes in the current year to an HRA that may be one in your tax household who may be eligible for the exemptionused to pay premiums for the employer sponsored coverage, as for unaffordable coverage, add the premiums for the lowest costlong as the employee is informed of the contributions a reasona bronze plans that are offered through the Marketplace whereble time before the employee must decide whether to enroll in one or more of the members of your tax household who may bethe coverage. eligible for this exemption reside that would together cover all of these individuals. Health flex contributions: An employee or related individual's required contribution for employer sponsored coverage is re Use the Marketplace Coverage Affordability Worksheet to deduced by amounts the employer contributes in the current year termine whether you or another member of your tax household isto a cafeteria plan if the contributions may be used only to pay eligible for this coverage exemption.for medical care (and not taken as cash or other taxable benefits), and are available for use toward premiums for minimum es Example 3—unmarried individual with no dependentssential coverage. Cafeteria plan contributions that may be used and no employer coverage. Eastin is unmarried and has nofor expenses other than medical care do not reduce the required dependents. His household income is $40,000. He can't enroll incontribution. employer coverage for any month in 2015. The annual premium for the lowest cost bronze self only plan in Eastin's rating area is Opt out payments: An employee's required contribution for $5,000 and the maximum premium tax credit that he could claimemployer sponsored coverage is increased by amounts that an if he had enrolled in this coverage is $1,700. Eastin can claim theemployer would pay the employee for declining coverage under exemption for unaffordable coverage for 2015 because his rethe employer's health plan. In some cases, an employer may quired contribution is $3,300 ($5,000 minus $1,700), which ismake this opt out payment only if the employee both declines more than 8.05% of his household income ($3,220, which isthe coverage and also satisfies another condition (such as en $40,000 multiplied by 0.0805).rolling in coverage offered by the employee's spouse). If the employer imposes other conditions on receiving the opt out pay Short coverage gap (code “B”). You generally can claim ament (in addition to declining the employer's health coverage), coverage exemption for yourself or another member of your taxthe employee may treat the opt out payment as increasing the household for each month of a gap in coverage of less than 3employee's required contribution if the employee can demon consecutive months. If an individual had more than one shortstrate that he or she meets the conditions (such as enrolling in coverage gap during the year, the individual is exempt only forcoverage offered by the employee's spouse). the month(s) in the first gap. If an individual had a gap of 3 months or more, the individual isn't exempt for any of those For more information on the effect that these arrangements months. For example, if an individual had coverage for everyhave on an employee's required contribution for employer spon month in the year except February and March, the individual issored coverage, see Notice 2015 87. exempt for those 2 months. However, if an individual had cover age for every month in the year except February, March, and Determining an individual's required contribution— April, the individual isn't exempt for any of those months.Individuals not eligible for coverage under an employerplan. If you or another member of your tax household can't pur Example—multiple gaps in coverage. Colton had coverchase coverage under an employer plan, the individual's re age for every month except February, March, October, and No vember. Colton is eligible for the short coverage gap exemption only for February and March. -9-

Example—gaps in coverage for partial months. Fred has Continuous coverage gap straddles more than one taxa-minimum essential coverage except for the period April 5 ble year. If you do not have minimum essential coverage for athrough July 25. An individual is treated as having coverage for continuous period that begins in one taxable year and ends inany month in which he or she has coverage for at least 1 day of the next, for purposes of applying the short coverage gap rulesthe month. As a result, Fred has minimum essential coverage in to the first taxable year, the months in the second taxable yearApril and July and is eligible for the short coverage gap exemp included in the continuous period are not counted. For purposestion for May and June. of applying the short coverage gap rules to the second year, the months in the first taxable year are counted.Affordability WorksheetUse this worksheet to determine whether coverage for each individual in your tax household is unaffordable. If you or another memberof your tax household isn't eligible for employer sponsored coverage, use the Marketplace Coverage Affordability Worksheet to figurethe required contribution for that individual. An individual is exempt for any month in which (B), the Required Contribution, is more than(A), the Affordability Threshold. (A) Affordability Threshold Enter 8.05% of your household income (see Household income). For this purpose, increase household income by the amount of any premium that is paid through a salary reduction arrangement and excluded from gross income. (B) Required Contribution Amount For each member of your tax household, enter in the columns provided the annual premium for the first option below that applies to that person. If the monthly premium is the same for the whole year, enter the annual premium in the space for each month. If the premiums cover only part of the year, use the Annualized Premium Worksheet to determine what the annualized premium would be for each month. Once you have figured the annualized premium, enter it in the space for each month. Options (use the first that applies to each member of your tax household, including you, for each month): 1. The lowest cost self only policy offered to each member of your tax household by his or her employer. 2. The lowest cost family policy* offered by your employer or your spouse's employer (if you are filing a joint return). 3. The amount from the Marketplace Coverage Affordability Worksheet. For each individual, coverage is unaffordable and the individual is exempt for any month in which (B), the Required Contribution Amount, is more than (A), the Affordability Threshold. Members of your tax household (enter one name per column): Annualized premium for: January February March April May June July August September October November December *The policy must cover everyone in your tax household: For whom a personal exemption deduction is claimed on your tax return, Who isn't eligible for employer coverage, and Who doesn't qualify for another coverage exemption. -10-

Marketplace Coverage Affordability WorksheetUse this worksheet to figure an individual's required contribution for any month in which the individual isn't eligible for employer sponsored coverage. Complete a separate worksheet for each part of the year in which either the individual resided in different geographicrating areas served by the Marketplace or for which the number of people in your tax household who are neither exempt nor eligible forminimum essential coverage (other than coverage in the individual market) was different. ! Do not complete this worksheet unless you were instructed to do so in the Affordability Worksheet.CAUTION1. Enter the monthly premium for the lowest cost bronze plan that covers everyone in your tax household for whom a personal exemption deduction is claimed, who isn't eligible for employer coverage, and who doesn't qualify for another coverage exemption for the month. To find the lowest cost bronze plan go to www.HealthCare.gov/tax-tool or the Marketplace for your area. If you are married and file a separate return, enter the monthly premium here and on line 12. Don't complete lines 2 through 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. Enter your household income (see Household income) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. Enter the total of all nontaxable social security benefits received by you, your spouse, and each claimed dependent who must file a tax return* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. Add lines 2 and 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. Enter the federal poverty line for the number of individuals in your tax household less any dependents not claimed. See the instructions for Form 8962, line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. Divide line 4 by line 5. If the result (without rounding) is less than 1.0 or more than 4.0, skip lines 7 through 10 and enter 0 on line 11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7. Multiply line 6 by 100 and round down to the nearest whole number. Enter the applicable figure for the result from the table in the instructions for Form 8962, line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8. Multiply line 4 by line 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9. Divide line 8 by 12.0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. Enter the monthly premium for the second lowest cost silver plan premium that covers everyone in your tax household for whom a personal exemption deduction is claimed, who isn't eligible for minimum essential coverage (other than coverage in the individual market), and who doesn't qualify for another coverage exemption for the month. To find the second lowest cost silver plan go to www.HealthCare.gov/tax-tool or the Marketplace for your area . . . . . . . . . . . . . . . . . . . . . . . .11. Subtract line 9 from line 10. If zero or less, enter 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12. Subtract line 11 from line 1. If zero or less, enter 0 . This is the individual's required contribution for the month . . . . . . .13. Is the individual eligible for this coverage for every month of the year? Yes. Multiply line 12 by 12.0. This is the annualized premium. Enter this amount in the space for every month on the Affordability Worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No. Multiply line 12 by 12.0. This is the annualized premium. Enter this amount in the space on the Affordability Worksheet for each month the individual was eligible for the coverage being tested . . . . . . . . . . . . . . . . . . . . . .*If the individual filed Form 1040, figure the nontaxable social security benefits received by that individual by subtracting Form 1040, line 20b from Form 1040,line 20a. If the individual filed Form 1040A, figure the nontaxable social security benefits received by that individual by subtracting Form 1040A, line 14b from Form1040A, line 14a. If the individual filed Form 1040EZ, he or she should have received a Form SSA 1099 or Form RRB 1099 showing the social security benefitsreceived by that individual, all of which were nontaxable. Example—Continuous coverage gap straddles more Citizens living abroad and certain noncitizens (code “C”).than one taxable year. Fran, an unmarried taxpayer with no You can claim a coverage exemption for yourself or anotherdependents, has minimum essential coverage from January 1 member of your tax household to which any of the following apthrough October 31, 2015. Fran is without coverage until Febru ply.ary 1, 2016. On her tax return for 2015, November and December of 2015 are treated as a short coverage gap. On her 2016 The individual is a U.S. citizen or a resident alien who istax return, November and December of 2015 are included in the physically present in a foreign country (or countries) for at leastcontinuous period that includes January 2016. The continuous 330 full days during any period of 12 consecutive months. Youperiod for 2016 is not less than 3 months, and therefore January can claim the coverage exemption for any month during your taxis not part of a short coverage gap. year that is included in the 12 month period. For more informa tion, see Physical Presence Test in Pub. 54, Tax Guide for U.S. To claim this coverage exemption, enter code “B” in Part III, Citizens and Resident Aliens Abroad.column (c), and identify the months to which the exemption applies as described under Columns (d) - (p)—Calendar Months, The individual is a U.S. citizen who is a bona fide residentlater. of a foreign country (or countries) for an uninterrupted period which includes an entire tax year. You can claim the coverage -11-

exemption for the entire year. For more information, see Bona cluding an Alaska Native Claims Settlement Act (ANCSA) CorFide Residence Test in Pub. 54. poration Shareholder (regional or village), for at least 1 day in the month. The list of Federally-recognized Indian tribes is available The individual is a resident alien who is a citizen or national at www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/of a foreign country with which the U.S. has an income tax treaty TribalDirectory. The list of village or regional corporations formedwith a nondiscrimination clause and who is a bona fide resident under ANCSA is available at dnr.alaska.gov/mlw/trails/17b/of a foreign country for an uninterrupted period that includes an corpindex.cfm. You can also claim a coverage exemption forentire tax year. You can claim the coverage exemption for the yourself or another member of your tax household for any monthentire year. For more information, see Bona Fide Residence in which the individual was eligible for services through an IndianTest in Pub. 54. health care provider or through the Indian Health Service. The individual is a bona fide resident of a U.S. territory. You To claim either of these coverage exemptions, enter code “E”can claim the coverage exemption for the entire year. in Part III, column (c), and identify the months to which the ex emption applies as described under Columns (d) - (p)—Calen- The individual is not lawfully present in the U.S. and is not a dar Months, later.U.S citizen or U.S. national. For this purpose, an immigrant withDeferred Action for Childhood Arrivals (DACA) status is not con If you or another member of your tax household wassidered lawfully present and therefore qualifies for this exemption. For more information about who is treated as lawfully TIP a member of a Federally-recognized Indian tribe andpresent for purposes of this coverage exemption, visitwww.HealthCare.gov. was granted a coverage exemption by the Market- place, see the instructions for Part I, earlier, to claim The individual is a nonresident alien, including (1) a du the exemption.al status alien in the first year of U.S. residency and (2) a nonresident alien or dual status alien who elects to file a joint return Incarceration (code “F”). You can claim a coverage exempwith a U.S. spouse. You can claim the coverage exemption for tion for yourself or another member of your tax household for anythe entire year. This exemption doesn't apply if you are a nonres month in which the individual was incarcerated for at least 1 dayident alien for 2015, but met certain presence requirements and in the month. For this purpose, an individual is considered incarelected to be treated as a U.S. resident. For more information cerated if he or she was confined, after the disposition of chargsee Pub. 519. es, in a jail, prison, or similar penal institution or correctional fa cility. To claim this coverage exemption, enter code “F” in Part III, To claim this coverage exemption, enter code “C” in Part III, column (c), and identify the months to which the exemption apcolumn (c), and identify the months to which the exemption ap plies as described under Columns (d) - (p)—Calendar Months,plies as described under Columns (d) - (p)—Calendar Months, later.later. If you meet one of these conditions, you qualify for this exemption even if you have a social security number (SSN). TIP If you or another member of your tax household was incarcerated and was granted a coverage exemptionMembers of a health care sharing ministry (code “D”). You by the Marketplace, see the instructions for Part I,can claim a coverage exemption for yourself or another member earlier, to claim the exemption.of your tax household for any month in which the individual wasa member of a health care sharing ministry for at least 1 day in Aggregate self-only coverage considered unaffordablethe month. Enter code “D” in Part III, column (c), and identify the (code “G”). You and any other members of your tax householdmonths to which the coverage exemption applies as described for whom you claim a personal exemption can claim a coverageunder Columns (d) - (p)—Calendar Months, later. exemption for all months in 2015 if, for at least 1 month in 2015: In general, a health care sharing ministry is a tax exempt or 1. The cost of self only coverage through employers for twoganization whose members share a common set of ethical or re or more members of your tax household doesn't exceed 8.05%ligious beliefs and share medical expenses in accordance with of household income when tested individually,those beliefs, even after a member develops a medical condition. The health care sharing ministry (or a predecessor) must 2. The cost of family coverage that the members of your taxhave been in existence and sharing medical expenses continu household described in condition 1 could enroll in through anously and without interruption since December 31, 1999. An indi employer exceeds 8.05% of household income, andvidual who is unsure whether a ministry meets the requirementsshould contact the ministry for further information. 3. The combined cost of the self only coverage identified in condition 1 exceeds 8.05% of household income. TIP If you or another member of your tax household was a member of a health care sharing ministry and was Example 1—two offers of self-only coverage that togeth-emption. granted a coverage exemption by the Marketplace, er are unaffordable. Justin and Sally are married, have no de see the instructions for Part I, earlier, to claim the ex- pendents, and file a joint return. Justin is offered self only cover age through his employer at a cost of 6% of the householdMembers of Indian tribes or individuals otherwise eligible income and is offered family coverage that would cover both Salfor services from an Indian health care provider (code “E”). ly and him at a cost of 10% of the household income. Sally is ofYou can claim a coverage exemption for yourself or another fered self only coverage through her employer at a cost of 5% ofmember of your tax household for any month in which the indi the household income but isn't offered family coverage. Sallyvidual was a member of a Federally recognized Indian tribe, in and Justin both may claim the coverage exemption for two or more members of a tax household whose combined cost of em ployer sponsored coverage is considered unaffordable because -12-

the self only coverage offered to Justin and Sally doesn't exceed For purposes of this exemption, your household income is in8.05% of the household income when tested individually, the creased by the amount of any nontaxable social security benefitscost of family coverage exceeds 8.05% of the household in received by you, your spouse (if filing jointly) or a dependent youcome, and the combined cost of the self only coverage offered claimed that must file his or her own tax return. To see if yourto Justin and Sally exceeds 8.05% of the household income. household income is less than 138% of the federal poverty line for the number of individuals in your tax household, not including Example 2—affordable family coverage. The facts are the any dependents you didn't claim, see the instructions for Formsame as in Example 1 except Justin’s employer offers family 8962, line 4.coverage that would cover both Sally and him at a cost of 7% ofthe household income. Neither Justin nor Sally may claim the To claim this coverage exemption, enter code “G” in Part III,coverage exemption for two or more members of a tax house column (c), and check the box in column (d).hold whose combined cost of employer sponsored coverage isconsidered unaffordable, because the family coverage offered TIP If you were granted a similar coverage exemption forby Justin's employer covers both Justin and Sally and its cost individuals who resided in a state that didn't expanddoesn't exceed 8.05% of the household income. Medicaid, see the instructions for Part I, earlier, to re- port the exemption. Example 3—one spouse enrolls in coverage. The factsare the same as in Example 1 except Justin enrolls in the Member of tax household born, adopted, or died (Codeself only coverage offered by his employer. Sally may claim the “H”). If you had or adopted a child during 2015, you can claim acoverage exemption for two or more members of a tax house coverage exemption for that child for the months before the childhold whose combined cost of employer sponsored coverage is was born or adopted. If a member of your tax household diedconsidered unaffordable. during 2015, you can claim a coverage exemption for the months following his or her death. To claim this coverage ex To claim this coverage exemption, enter code “G” in Part III, emption, enter code \"H\" in Part III, column (c), and identify thecolumn (c), and check the box in column (d). months to which the exemption applies as described under Col- umns (d) - (p)—Calendar Months.Resident of a state that did not expand Medicaid (code“G”). You can claim a coverage exemption for yourself or an Columns (d) – (p)—Calendar Monthsother member of your tax household for 2015 if: For each coverage exemption claimed in column (a), check the Your household income is less than 138% of the federal appropriate box or boxes for the months for which the particularpoverty line for the number of individuals in your tax household, exemption applies. If the coverage exemption applies for the fullnot including any dependents you didn't claim; and year, check the box in column (d) and don't check the boxes in columns (e) – (p). At any time in 2015 the individual resided in Alabama, Alaska, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine,Mississippi, Missouri, Montana, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah,Virginia, Wisconsin, or Wyoming. -13-

Shared Responsibility 3. Do you, your spouse (if filing jointly), or anyone else youPayment claimed or could have claimed as a dependent have qualifying health coverage or qualify for a coverageTo Figure Your Shared Responsibility exemption for any month in 2015?Payment Yes. STOP No. Continue Claim any coverage Follow Steps 1 through 5 next. exemption you qualify ᮢ Complete Worksheet A and Worksheet B if you are directed to for on Form 8965. Skipthem as you complete Steps 1 through 5. questions 4 and 5; go to Complete the Shared Responsibility Payment Worksheet as Worksheet A.directed by Steps 1 through 5 or Worksheets A and B.Step 1 All Filers 4. Did you elect not to claim a dependent you could have claimed?1. Can someone claim you as a dependent? Yes. STOP No. Continue Skip question 5; go toYes. STOP No. Continue Worksheet A. ᮢYou do not owe ashared responsibility ᮢpayment. Do not checkthe box on line 6a of 5. Did you, your spouse (if filing jointly), or any of yourForm 1040 or Form dependents turn 18 during 2015?1040A. If you file Form1040EZ, check the box Yes. Go to No. Go to Step 2.on line 5. Worksheet A.2. Did you, your spouse (if filing jointly), and everyone you Step 2 Flat Dollar Amount claimed or could have claimed as a dependent have qualifying health coverage for every month of 2015*? 1. Multiply $325 for each person for whom you claimed an exemption on line 6d of Forms 1040 or 1040A who was atYes. STOP No. Continue least 18 years old.* Multiply $325 by each person forYou do not owe a whom you did not check a box on Form 1040EZ, line 5,shared responsibility ᮢ who is at least 18 years old.payment. Check the 1Full-year coveragecheckbox on Form *For purposes of figuring the shared responsibility payment, an individual is considered under1040, line 61; Form age 18 for an entire month if he or she didn't turn 18 before the first day of the month. An1040A, line 38; or individual turns 18 on the anniversary of the day the individual was born.Form 1040EZ, line 11. 2. Multiply $162.50 for each person for whom you claimed an*You can check the Full-year coverage box if you had or adopted a child during the year, or a exemption on line 6d of Forms 1040 or 1040A who wasmember of your tax household died during the year, as long as that person had qualifying under age 18. Multiply $162.50 by each person for whomhealth care coverage for every month he or she was a member of your tax household. you did not check a box on Form 1040EZ, line 5, who is under age 18. 2 3. Add lines 1 and 2. 3 4. Enter the smaller of line 3 or $975 here and on line 1 of the Shared Responsibility Payment Worksheet. Go to Step 3. 4 -14-

Step 3 Household Income 7. Is Form 8814, line 4 more than $1,050?1. Enter the amount from Form 1040, line 38; Form 1040A, Yes. Add the amount No. Enter -0- below. line 21; or Form 1040EZ, line 4. from Form 8814, 1 line 1b and the smaller Continue of Form 8814, line 4 or 5. ᮢ 72. Did you receive any tax-exempt interest?Yes. Enter the amount No. Continue 8. Add lines 1, 2, 3, 5, and 7. This is your householdfrom Form 1040, income. Enter the result on Step 4, line 1.line 8b; Form 1040A, ᮢ 8line 8b; or the amountentered in the space tothe left of Form1040EZ, line 2. 2 Step 4 Percentage Income Amount3. Did you attach Form 2555 or Form 2555-EZ? 1. Enter your household income from Step 3. 1Yes. Enter the amount No. Continuefrom Form 2555, lines45 and 50; or Form ᮢ2555-EZ, line 18. 2. Were you or your spouse (if filing jointly) born before January 2, 1951? 3 Yes. Skip question 3. No. Go to question 3. Find your filing4. Did you claim any dependents? No. STOP threshold on the Filing Add lines 1 through 3. Thresholds For Most Yes. Continue This is your household People chart and enter income. Enter the result it both here and on ᮢ on Step 4, line 1. line 4. 25. Were any of the dependents you claimed required to file a 3. Enter the amount listed below for your filing status. return? Single—$10,300 Head of household—$13,250Yes. Complete No. Add lines 1 through Married filing jointly—$20,600questions 1 through 3 3. This is your Married filing separately—$4,000for each dependent with household income. Qualifying widow(er) with dependent child—$16,600a filing requirement for Enter the result on Stepwhom you did not 4, line 1. 3attach Form 8814.Enter the total here. 5 4. Enter the amount from line 2 or 3. 46. Did you attach Form 8814? No. STOP 5. Subtract line 4 from line 1. Add lines 1, 2, 3, and 5. Yes. Continue This is your household income. Enter the result ᮢ on Step 4, line 1. 5 -15-

6. Is the amount on line 5 zero or less? Step 5 National Average Bronze Plan PremiumYes. STOP No. ContinueYou do not owe ashared responsibility ᮢpayment. CompleteForm 8965 by checking 1. Were you required to complete Worksheet A?the “Yes” box online 7a. Yes. Continue No. Skip question 2; Go to question 3. ᮢ7. Multiply line 5 by 2.0% (0.02). This is your percentage of 2. Multiply $207* by the number on Worksheet A, line 8. income amount. Enter the result here and on line 4 of the Shared 7 Responsibility Payment Worksheet. Skip question 3 and complete line 5 of the Shared Responsibility Payment Worksheet. 28. Were you required to complete Worksheet A?Yes. Go to No. STOP *$207 is the 2015 national average premium for a bronze level health plan available through the Marketplace for one individual for one month.Worksheet B. Enter the amount fromContinue line 7 on line 2 of the Shared Responsibility ᮢ Payment Worksheet and complete line 3 of that worksheet. 3. Enter on line 4 of the Shared Responsibility Payment Worksheet, the amount below that corresponds to the total number of exemptions you claimed on line 6d of Form 1040 or Form 1040A. If you filed Form 1040EZ, enter the amount below that corresponds to the number of boxes left unchecked on line 5 of Form 1040EZ. Then complete line 5 of the Shared Responsibility Payment Worksheet. 1 exemption—$2,484 2 exemptions—$4,968 3 exemptions—$7,452 4 exemptions—$9,936 5 or more exemptions—$12,420Shared Responsibility Payment Worksheet1. Enter the flat dollar amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12. Enter the percentage income amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23. Enter the larger of line 1 or line 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34. Enter the National Average Bronze Plan Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45. Enter the smaller of line 3 or line 4 here and on Form 1040, line 61; Form 1040A; line 38; or Form 1040EZ, line 11. This is your shared responsibility payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 -16-

Worksheet AUse this worksheet if you were referred here from Step 1 under Shared Responsibility Payment. After completing the worksheet, goto Step 3 under Shared Responsibility Payment. If everyone in your tax household had either minimum essential coverage or acoverage exemption for every month during 2015, stop here. You do not owe a shared responsibility payment. Complete the monthly columns by placing “X's” in each month in which you or another member of your tax household had neither minimum essential coverage nor a coverage exemption. Name Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1. Total number of X's in a month. If 5 or more, enter 5 . . . . . . . . . . . . . . . . . . 2. Total number of X's in a month for individuals 18 or over* . . . . . . . . . . . . 3. One-half the number of X's in a month for individuals under 18* . . . . . . . . . . . . . 4. Add lines 2 and 3 for each month . . . . . 5. Multiply line 4 by $325 for each month. If $975 or more, enter $975 . . . . . . . . . . 6. Add the amounts for each month on line 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Divide line 6 by 12.0. This is your flat dollar amount. Enter this amount on line 1 of the Shared Responsibility Payment Worksheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8. Add the amounts entered for each month on line 1. Go to Step 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .*For purposes of figuring the shared responsibility payment, an individual is considered under 18 for an entire month if he or she didn't turn 18 before the firstday of the month. An individual turns 18 on the anniversary of the day the individual was born. For example, someone born on March 1, 2000, is consideredage 18 on March 1, 2018, and, therefore, isn't considered age 18 for purposes of the shared responsibility payment until April 2018. -17-

Worksheet B ! Do not complete this worksheet unless you were directed here in Step 4 under Shared Responsibility Payment.CAUTIONFor each month, you must determine if the amount on line 5 of Worksheet A is less than (a) (b) (c)the amount on line 7 of Step 4 under Shared Responsibility Payment * Enter the Enter the Enter the larger amount from amount from of column (a) or Step 4, line 7 line 5 column (b)1. January . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2. February . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3. March . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4. April . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5. May . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. June . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7. July . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8. August . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9. September . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10. October . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11. November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12. December . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13. Add the amounts in column (c) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14. Divide line 13 by 12.0. Enter the result on lines 2 and 3 of the Shared Responsibility Payment Worksheet. Go to Step 5 ............................................................................*If the amount on line 1 of Worksheet A is -0- for any month, leave all columns of this worksheet blank for that month.Filing Thresholds For Most PeopleIF your filing status is... AND at the end of 2015 you were*... THEN you must file a tax return if your gross income** is more than...Single Under 65 $10,300 65 or older $11,850Head of Household Under 65 $13,250 65 or older $14,800Married Filing Jointly*** Under 65 (both spouses) $20,600 65 or older (one spouse) $21,850 65 or older (both spouses) $23,100Married Filing Separately Any age $4,000Qualifying Widow(er) with Dependent children Under 65 $16,600 65 or older $17,850*If you were born on January 1, 1951, you are considered to be age 65 at the end of 2015. (If your spouse died in 2015 or if you are preparing a return forsomeone who died in 2015, see Pub. 501.)**Gross income means all income you received in the form of money, goods, property, and services that isn't exempt from tax, including anyincome from sources outside the United States. It also includes gain from the sale of your main home, even if you can exclude part or all of it.Include only the taxable part of social security benefits (Form 1040, line 20b; Form 1040A, line 14b). Also include gains, but not losses,reported on Form 8949 or Schedule D. Gross income from a business means, for example, the amount on Schedule C, line 7, or Schedule F,line 9. But, in figuring gross income, don't reduce your income by any losses, including any loss on Schedule C, line 7, or Schedule F, line 9.***If you did not live with your spouse at the end of 2015 (or on the date your spouse died) and your gross income was at least $4,000, you must file a returnregardless of your age. -18-

How To Avoid Common Mistakes Mistakes in figuring your Shared Responsibility PaymentMistakes in completing Form 8965 or figuring your shared responsibility payment can cause you to pay too much tax, delay Before making a shared responsibility payment:the processing of your return or refund, or cause you to receive Make sure you can't check the full year coverage checkboxnotices or other correspondence from the IRS. Review the listbelow to avoid making common mistakes on your return. on your tax return. See the instructions for Form 1040, line 61; Form 1040, line 38; or Form 1040EZ, line 11.Mistakes in completing Form 8965 Make sure you can't be claimed as a dependent on anotherPart II. You can claim a coverage exemption for yourself and person's tax return. See Exemptions for Dependents in Pub. 501everyone in your tax household if your gross income or house or Line 6c—Dependents in the instructions for Form 1040 orhold income are below the filing threshold. If you claim a cover 1040A. You do not owe a shared responsibility payment if youage exemption in Part II: can be claimed as a dependent by another taxpayer. Make sure you checked the \"Yes\" box on line 7a or 7b. Review the Types of Coverage Exemptions chart to see if If you are not claiming another coverage exemption, make you haven't overlooked a coverage exemption that may apply tosure you left Part I and III blank. you or someone else in your tax household.Part III. You can claim a coverage exemption on your tax return Make sure that your gross income and household incomefor yourself or another member of your family. If you are claiming are more than the filing threshold that applies to you. See Step 3a coverage exemption in Part III: under Shared Responsibility Payment, earlier. You do not owe a shared responsibility payment if your gross income or household Make sure you entered one of the codes listed in the Types income are below the filing threshold.of Coverage Exemptions chart in column (c). Use only the codeslisted in the Types of Coverage Exemptions chart. Do not leave Make sure that the amount on line 1 of the Shared Responcolumn (c) blank. sibility Payment Worksheet (the flat dollar amount) is not more than $975. See Step 2 under Shared Responsibility Payment, If you have a coverage exemption that covers the entire earlier, for instructions on how to figure the flat dollar amount.year, make sure you check the \"Full Year\" box in column (d). Donot check any months in columns (e) through (p) for that exemp Make sure that your shared responsibility payment is nottion. more than line 4 of the Shared Responsibility Payment Work sheet (the National Average Bronze Plan Premium). See Step 5 under Shared Responsibility Payment, earlier, for instructions on how to figure the National Average Bronze Plan Premium that applies to you. -19-