Instructions For Form 8965 - Health Coverage Exemptions

Incarceration (code “F”). You can claim a coverage exemp-

Resident of a state that didn’t expand Medicaid (code “G”).

tion for yourself or another member of your tax household for any

You can claim a coverage exemption for yourself or another

month in which the individual was incarcerated for at least 1 day

member of your tax household for 2017 if:

in the month. For this purpose, an individual is considered incar-

Your household income is less than 138% of the federal

cerated if he or she was confined, after the disposition of charg-

poverty line for the number of individuals in your tax household,

es, in a jail, prison, or similar penal institution or correctional fa-

not including any dependents you didn't claim; and

cility. To claim this coverage exemption, enter code “F” in Part III,

At any time in 2017 the individual resided in Alabama, Flor-

column (c), and identify the months to which the exemption ap-

ida, Georgia, Idaho, Kansas, Maine, Mississippi, Missouri, Ne-

plies as described under

Columns (d) - (p)—Calendar

Months,

braska, North Carolina, Oklahoma, South Carolina, South Dako-

later.

ta, Tennessee, Texas, Utah, Virginia, Wisconsin, or Wyoming.

Aggregate self-only coverage considered unaffordable

For purposes of this exemption, your household income is in-

(code “G”). You and any other members of your tax household

creased by the amount of any nontaxable social security benefits

for whom you claim a personal exemption can claim a coverage

received by you, your spouse (if filing jointly), or a dependent

exemption for all months in 2017 if, for at least 1 month in 2017,

you claimed that must file his or her own tax return. To see if

all of the following apply.

your household income is less than 138% of the federal poverty

line for the number of individuals in your tax household, not in-

1. The cost of self-only coverage through employers for two

cluding any dependents you didn't claim, complete lines 2

or more members of your tax household doesn't exceed 8.16%

through 6 of the

Marketplace Coverage Affordability

Worksheet.

of household income when tested individually,

2. The cost of family coverage that the members of your tax

Federal poverty line. Use the following tables to determine

household described in condition 1 could enroll in through an

the applicable federal poverty line. If you moved during 2017 and

employer exceeds 8.16% of household income, and

you lived in Alaska and/or Hawaii, or you are filing jointly and you

and your spouse lived in different states, use the table with the

3. The combined cost of the self-only coverage identified in

higher dollar amounts for your tax household.

condition 1 exceeds 8.16% of household income.

Federal Poverty Line for the 48 Contiguous States and the

Example 1—Two offers of self-only coverage that to-

District of Columbia

gether are unaffordable. Justin and Sally are married, have no

IF the size of your

THEN the federal

dependents, and file a joint return. Justin is offered self-only cov-

tax household* is. . .

poverty line is. . .

erage through his employer at a cost of 6% of the household in-

$11,880

come and is offered family coverage that would cover both Sally

$16,020

and him at a cost of 10% of the household income. Sally is of-

$20,160

fered self-only coverage through her employer at a cost of 5% of

$24,300

the household income and isn't offered family coverage. Sally

$28,440

and Justin both may claim the coverage exemption for two or

$32,580

more members of a tax household whose combined cost of em-

$36,730

ployer-sponsored coverage is considered unaffordable because

$40,890

the self-only coverage offered to Justin and Sally doesn't exceed

*If your tax household is more than 8 people, add $4,160 for each additional

8.16% of the household income when tested individually, the

person. For example, if your tax household is 11, you have 3 additional

cost of family coverage exceeds 8.16% of the household in-

people. Multiply $4,160 by 3 and add the result of $12,480 to $40,890.

come, and the combined cost of the self-only coverage offered

to Justin and Sally exceeds 8.16% of the household income.

Federal Poverty Line for Alaska

Example 2—Affordable family coverage. The facts are

IF the size of your

THEN the federal

the same as in Example 1 except Justin’s employer offers family

tax household* is. .

poverty line is. . .

coverage that would cover both Sally and him at a cost of 7% of

$14,840

the household income. Neither Justin nor Sally may claim the

$20,020

coverage exemption for two or more members of a tax house-

$25,200

hold whose combined cost of employer-sponsored coverage is

$30,380

considered unaffordable, because the family coverage offered

$35,560

by Justin's employer covers both Justin and Sally and its cost

$40,740

doesn't exceed 8.16% of the household income.

$45,920

Example 3—One spouse enrolls in coverage. The facts

$51,120

are the same as in Example 1 except Justin enrolls in the

*If your tax household is more than 8 people, add $5,200 for each additional

self-only coverage offered by his employer. Sally may claim the

person. For example, if your tax household is 11, you have 3 additional

coverage exemption for two or more members of a tax house-

people. Multiply $5,200 by 3 and add the result of $15,600 to $51,120.

hold whose combined cost of employer-sponsored coverage is

considered unaffordable.

To claim this coverage exemption, enter code “G” in Part III,

column (c), and check the box in column (d).

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Instructions For Form 8965 - Health Coverage Exemptions - 2016 Page 13

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