Basic Filing Information:

Taxpayer's Name:
Tax Year:			Region:  48 states   Alaska   Hawaii State expanded Medicaid? Yes   No   State has ACA Basic Health Program? Yes   No
Filing Status:	Single MFJ MFS HOH Widow(er)	TP 65 or older in SP 65 or older in	Filing Threshold: 100% Fed Poverty Line: 138% Fed Poverty Line: 400% Fed Poverty Line:
Number of dependents:

Affordability does not apply for tax years 2019 and later

Household Income Information:

Enter amounts from tax returns only for those dependents who must file other than to obtain a refund of withholding or estimated payments.

Amount	Location	TP & SP	Depend 1	Depend 2	Depend 3	Depend 4	Depend 5
AGI
Tax-exempt interest
Social Security Income
Taxable Social Security
Foreign Income
Form 1040 cap gain/loss	Form 1040 line 13		}
Adjustments to income	Form 1040 line 36
Main Home Sale exclusion	Sched D & Forms 8949
Schedule D gains	Sched D & Forms 8949
Business expenses/losses	Sched C, lines 28 + 30
		Total	Comments			Total dependent MAGI For use in TaxSlayer 1095A reconciliation:
Household Income (MAGI)	(for Form 8965)		Used for affordability test
Gross Income			Used for affordability test
Household Income (MAGI)	(for Form 8962)		Used for PTC/APTC calc
Click to test Was any family member: a) offered employer coverage, or b) already insured, or c) eligible for government insurance? - If Yes, CONTINUE to the next test - If No, STOP! Household Income (including untaxed Social Security) is less than 249% of FPL. The family cost will be less than % of household income affordability threshold. The affordability exemption will not apply. STOP! Household Income (including untaxed Social Security) is less than 138% of FPL and is from a state that did not expand Medicaid. Use exception code G (Resident of a state that did not expand Medicaid) in Form 8965 part III for each person not covered. STOP! Gross Income is less than the filing threshold (). Further information STOP! Household Income is less than the filing threshold (). Further information GO TO NEXT TEST... No special conditions apply.

Affordability Income:

Total premiums paid through salary reduction and excluded from income		Adjusted Annual Income =  Affordability threshold at % =
NOTE: This amount is compared with insurance premium costs to determine affordability in the next worksheet.

Affordability Worksheet: (Tests for Code A or Code G for Form 8965 part III)

Use Monthly or Annualized amounts 

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• Above line 1 in the table below, select:
  • "NO" for those that have no other exemption, have no coverage, and are not eligible for government-sponsored coverage (Medicare, Medicaid, CHIP, etc).
  • "EXM" for any person that is covered by another exemption.
  • "MEC" if they already have insurance for the months being tested.
    • If by employer, see employer offers below
    • If by government-sponsored (Medicare, Medicaid, CHIP, etc), use GOV.
  • "GOV" for anyone eligible for government insurance regardless of whether they have taken that coverage to exclude them from the PTC. (The actual cost of GOV coverage is never used so do not enter it anywhere.)
    • Click here for an explanation of how to deal with more generous government programs. (Basic Health Plans in NY and MN, pregnant women in many other states)
    • If also eligible for employer coverage, see employer offers below
• Employer offers:
  • Enter the lowest cost employer offered insurance for self-only (line 1) and family (line 2), if there is one, that apply to each person. Use "0" if there is no charge for it.
    Include the cost of a stand-alone policy offered for a family member when that member is not eligible for the family offer, e.g. dependent child over age 26.
  • Check the small box to the right if the employer insurance was taken (even if it had "0" cost).
  • If employer coverage premiums include a partial month of coverage, you must use the Annualized Premium Worksheet Click to open
    

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    The total premium amount for the period (paid or not):
    The number of full months covered in the period:
    The amount to enter in line 1 or 2 below is: 0.00 (this will apply to all months in the period)

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  • If more than one family plan is entered, the lowest will be used for those needing an exemption. If a person is not eligible for that family plan, place an "X" in their family plan box. If that person is eligible for the higher cost family plan only, manually enter the higher cost amount. You will need to do this each time you run the test.
• Click on the "Click to test" button. Family plan amounts will carry across to all eligible family members for whom you have not manually entered a different amount.
• A " ? " in the "Click to test" row means you need to complete the Marketplace Coverage Affordability Worksheet.
• If there is no employer offer to enter, proceed to the Marketplace Coverage Affordability Worksheet to calculate the amount that will be used for line 3.
• After completing the LCBP and SLCSP quotes, click the "Click to test" button to carry the result to line 3 and to fill corresponding month boxes. Do not include GOV costs (CHIP, Medicaid, Medicare, etc) in any calculation.

If the taxpayer's situation changes during the year,

• Check the box to the left of the month to indicate the months' calculations that you want to keep.
• Update NO, EXM, MEC or GOV above line 1, and all line 1 and 2 data for the new situation (not salary reduction premiums entered above) and
• Update the quotes in the Marketplace Coverage Affordability Worksheet and then,
• Re-click "Click to test". Unchecked months will be modified based on the taxpayer's new situation.
• Repeat these steps until all months' circumstances have been determined.

To facilitate input into TaxSlayer, click to use the annualized amounts option immediately above these instructions and print out the results for the reviewer and for the taxpayer's records.

Transfer the results to the TaxSlayer Health Insurance section and verify that Form 8965 Part III has the proper exceptions.

• Any resulting exemptions that are not needed can be ignored.
• For Code A, choose TaxSlayer option "Coverage is unaffordable".
• For Code G, choose TaxSlayer option "Aggregate self-only coverage considered unaffordable".

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Affordability threshold =  

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	Taxpayer	Spouse	Depend 1	Depend 2	Depend 3	Depend 4	Depend 5
Exempt by another code, MEC or GOV?	NO GOV MEC EXM	NO GOV MEC EXM	NO GOV MEC EXM	NO GOV MEC EXM	NO GOV MEC EXM	NO GOV MEC EXM	NO GOV MEC EXM
1. Lowest cost self-only policy     offered by employer
2. Lowest cost family policy     offered by employer
	It appears there are two differently-costed family plan offers by employers. Is the Spouse included in the Taxpayer's family plan? Yes No Is the Taxpayer included in the Spouse's family plan? Yes No
3. Amount from Marketplace Coverage     Affordability Worksheet line 12
Click to test Use exemption code:
January
February
March
April
May
June
July
August
September
October
November
December
ANNUALIZED COST FOR PERIOD:
PERCENT OF HOUSEHOLD INCOME:

Marketplace Coverage Affordability Worksheet			To get Bronze and Silver plan costs, use: https://www.healthcare.gov/tax-tool/ or your state exchange: Change Save ⇐ Enter your state exchange URL or, as a last resort, http://www.healthpocket.com
Check this box if this is a test for a portion of the year when the Taxpayer earns enough to be ineligible for Medicaid (/mo) thus eligible for PTC.
1. Monthly lowest cost Bronze plan       :			Lowest Bronze plan premium amount using 's age .
2. Household income:			Household income without untaxed Social Security
3. Nontaxable Social Security:			Includes nontaxed Social Security for all tax family members
4. Add lines 2 + 3:			Household income with untaxed Social Security
5. Fed Poverty Line:
6. Divide line 4 by line 5:
7. Multiply line 6 by 100       and look up: .			Value is from col 2 of the Form 8962 Instructions for line 7.
8. Multiply line 4 by line 7:			TP's annual contribution amount before PTC
9. Divide line 8 by 12:			TP's monthly contribution amount before PTC
10. Monthly second lowest cost       Silver plan       :			Second lowest Silver plan premium amount using 's age .
11. Subtract line 9 from line 10:			Maximum PTC amount allowed (but limited by the Bronze plan cost)
12. Subtract line 11 from line 1:			Cost to the taxpayer after PTC is applied
13. Return to the Affordability Worksheet above and click the "Click to test" button.(go there)