Instructions For Form 8965 - Health Coverage Exemptions

Marketplace Coverage Affordability Worksheet

Use this worksheet to figure an individual's required contribution for any month in which the individual isn't eligible for employer-spon-

sored coverage. Complete a separate worksheet for each part of the year in which either the individual resided in different geographic

rating areas served by the Marketplace or for which the number of people in your tax household who are neither exempt nor eligible for

minimum essential coverage (other than individual market coverage) was different.

Don’t complete this worksheet unless you were instructed to do so in the Affordability Worksheet.

CAUTION

Enter the monthly premium for the lowest cost bronze plan (or if no bronze plan is available through the Marketplace, the

lowest cost metal level 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 (or if no bronze plan is available through the Marketplace, the lowest cost metal level plan),

go to

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)

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Enter your household income (see

Household

income)

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Enter the total of all nontaxable social security benefits received by you, your spouse, and each claimed dependent who

must file a tax return

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Add lines 2 and 3

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Enter the

federal poverty line

for the number of individuals in your tax household less any dependents not claimed

. . . .

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

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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

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Multiply line 4 by line 7

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Divide line 8 by 12.0

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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

individual

market

coverage), and who doesn't qualify for another coverage exemption for the month. If one or more members of your

tax household meet this criteria, find the second lowest cost silver plan for those members at

or the Marketplace for your area. If no one in your tax household meets this criteria (for example, everyone in your tax

household is eligible for Medicaid or qualifies for a coverage exemption), enter -0-

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11. Subtract line 9 from line 10. If zero or less, enter -0-

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12. Subtract line 11 from line 1. If zero or less, enter -0-. This is the individual's required contribution for the month

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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 required contribution. Enter this amount in the space for every

month on the

Affordability Worksheet

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No. Multiply line 12 by 12.0. This is the annualized required contribution. Enter this amount in the space on the

Affordability Worksheet

for each month the individual was eligible for the coverage being tested

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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

Form 1040A, 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

benefits received by that individual, all of which were nontaxable.

If the result is less than 1.38 and you or another member of your tax household resided in a state that didn’t expand Medicaid, you can claim a coverage

exemption (see

Resident of a state that didn’t expand Medicaid (code

“G”)).

If the result is less than 1.38, you or another member of your tax household resided in a state that did expand Medicaid (states other than those listed at

Resident

of a state that didn’t expand Medicaid (code

“G”)), and you meet the Medicaid eligibility requirements, you’re eligible for Medicaid and therefore not eligible for a

premium tax credit. Enter -0- on line 10.

exempt for those 2 months. However, if an individual had cover-

Short coverage gap (code “B”). You generally can claim a

age for every month in the year except February, March, and

coverage exemption for yourself or another member of your tax

April, the individual isn't exempt for any of those months.

household for each month of a gap in coverage of less than 3

consecutive months. If an individual had more than one short

Example—Multiple gaps in coverage. Colton had cover-