You can view and download the PDF application here:  (click link below to open)

Application for Exemption from the Shared Responsibility Payment for Individuals who Experience Hardships

Possible reasons for exemption to the Tax Penalty

Exemptions From Having To Pay The Tax Penalty

♦ The individual is uninsured less than 3 consecutive months

♦ The lowest priced insurance plan available would cost more than 8.13% of the household income

♦ The individual does not have to file a tax return because income is too low

♦ The individual is a member of federally recognized Indian tribe

♦ The individual is a member of a health care sharing ministry

♦ The individual belongs to a religious sect with objections to receive insurance benefits and Social Security and Medicare

♦ The individual is incarcerated

♦ The individual is not legally present in the USA

♦ The individual has a hardship determined by the Dept. of HHS for example:

◊ Become homeless

◊ Has been evicted in the past 6 weeks or is facing eviction or foreclosure

◊ Child is denied Medicaid and CHIP and another person is Court ordered to cover that child

◊ Received a shut-off notice from a utility company

◊ Recent death of a close family member

◊ Recent fire, flood, natural or human-caused disaster resulting in substantial damage to individual property

◊ Filed bankruptcy in last 6 months

◊ Recent domestic violence

◊ Substantial medical debt in the last 2 yrs

◊ Unexpected expenses d/t caring for an ill, disabled, or aging family member

◊ Time frame to appeal and overturn a denial of eligibility to get a Marketplace plan

◊ Lost individual plan and believes other coverage options are unaffordable

◊ Other hardships obtaining health insurance

Authorized Agent for:  Nevada Health Link, Anthem Blue Cross and Blue Shield, Sierra Health and Life, Health Plan of Nevada, Aetna, Prominence Health Plan, Hometown Health, Golden Rule / United Health One