Affordable Care Act Information Intake Form Lucas Accounting (Page 3 of 3) in pdf

Affordable Care Act Information Intake Form Lucas Accounting Page 3

ACA Form 2

Coverage Exemptions for Individuals Claimed on Returns

Exemption

Full

Name of Individual

Type

Year

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

Exemption Key:

A Coverage is considered unaffordable (more than 8% of household income)

B Short coverage gap - without coverage for < 3 consecutive months

C Citizens living abroad and certain non-citizens

D Members of a health care sharing ministry

E Members of Federally-recognized Indian tribes

F Incarceration

G-1 Hardship - cost of employer sponsored coverage is >8% of household income

G-2 Hardship - You purchased insurance through Marketplace during the initial

enrollment period but have a coverage gap at the beginning of 2014

G-3 Hardship - You applied for CHIP coverage during the initial open enrollment

period but have a coverage gap at the beginning of 2014

H-1 Limited benefit Medicaid and TRICARE programs

H-2 Fiscal year employer-sponsored plan

MKT-1 Members of certain religious sects. Must have certificate from the Marketplace

MKT -2 Hardship - Circumstances that prevent you from obtaining coverage. Must have

certificate from the Marketplace

Follow this link to apply for an exemption certificate from the Marketplace:

https://

Taxpayer's Signature: _________________________________________________________________

Z:Lori PrederAffordable Care ActAffordable Care Act Information Intake Form ACA Form 2

Affordable Care Act Information Intake Form Lucas Accounting Page 3