PDF document

- 1 -

  Individual Health Insurance Mandate for Rhode Island Residents 
                  Individual Health Insurance Form and Shared Responsibility Worksheet

                                         GENERAL INSTRUCTIONS 
                                                                                return but choose to file anyway, enter “NC” for each month and for each 
                                                                                tax household member on Form IND-HEALTH. 
                    PURPOSE OF FORM                                              
                                                                                In Summary 
                                                                                If, during 2023, each individual who is a member of your tax household for 
Pursuant to R.I. Gen. Laws § 44-30-101, beginning after December 31,            any month had coverage for all the months they were members of your tax 
2019, Rhode Island residents are required to maintain health insurance,         household and residents of Rhode Island, you will check the “Full-year health 
known as “Minimum Essential Coverage” or be subject to a tax known as           care coverage” box on your return. 
the “Shared Responsibility Payment Penalty”. Rhode Island’s individual           
health insurance mandate is based, in part, on the federal mandate estab-       If, during 2023, one or more members of your tax household did not have 
lished under the Patient Protection and Affordable Care Act (Pub. Law           minimum essential coverage, complete Form IND-HEALTH being sure to list  
111-148).                                                                       ALL members of your tax household (not just those with months of non-
                                                                                coverage).  You will also need to complete the Shared Responsibility Work-
The Rhode Island Individual Health Insurance Mandate requires each ap-          sheet.  Be sure to attach both the form and the worksheet to your tax return. 
plicable individual to have health insurance coverage, have a health cover-         
age exemption, or make a shared responsibility payment with their Rhode             
Island personal income tax return.  
                                                                                                              DEFINITIONS
Forms RI-1040 and RI-1040NR include a checkbox on page 1 to indicate if 
all members of your tax household had minimum essential coverage for the                                                                                
full year.  Part-year residents filing Form RI-1040NR may check the check-       
box on page 1, line 15b if all members of the tax household had minimum         BIRTH, DEATH, OR ADOPTION 
essential health coverage for the months they were Rhode Island residents.      An individual is included in your tax household in a month only if he or she 
                                                                                is alive for the full month.  
Form IND-HEALTH and the Shared Responsibility Worksheet are to be                
used and filed with your personal income tax return if not all members of       Adoption: 
your tax household had minimum essential coverage for the full year, and        If you adopt a child during the year, the child is included in your tax house-
you are unable to check the "Full-year health care coverage" checkbox on        hold only for the full months that follow the month in which the adoption oc-
page 1 of Form RI-1040 or RI-1040NR.                                            curs.  
                                                                                 
Use these instructions to determine your Shared Responsibility Payment if       Use Coverage Exemption Code “H1” for the month in which the adoption 
for any month during the year you or another member of your tax household       occurred and for all of the months preceding that month. 
did not have minimum essential health coverage. If you can claim any part-       
year exemptions for specific members of your tax household, use Form IND-       For example, if you adopt a child on October 10, 2023, you would enter “H1” 
HEALTH form. This will reduce the amount of your shared responsibility          for the months of January through October on Form IND-HEALTH. 
payment.                                                                         
                                                                                 
Coverage exemptions                                                             Birth: 
If you cannot check the "Full-year health care coverage" checkbox on page       If you or your spouse gives birth during the year, the child is included in your 
1 of Form RI-1040 or RI-1040NR, Form IND-HEALTH must be completed.              tax household only for the full months that follow the month in which the birth 
If you or a member of your tax household did not have full-year health cov-     occurs. 
erage and were not granted an exemption, Form IND-HEALTH must still be           
completed.                                    DRAFT Use Coverage Exemption Code “H1” for the month in which the birth oc-
                                                                                curred and for all of the months preceeding that month. 
Shared responsibility payment                                                    
You must make a shared responsibility payment if, for any month, you or an-     For example, if you or your spouse gave birth in April of 2023, you would 
other member of your tax household did not have minimum essential health-       enter “H1” for the months of January through April on Form IND-HEALTH. 
care coverage or a coverage exemption. See the Shared Responsibility             
Worksheet to determine your payment, if any.  Report your Shared Respon-         
sibility Payment on Form RI-1040, line 12b or Form RI-1040NR, line 15b.         Death: 
                                                                                If a member of your tax household passes away during the year, the house-
Who Must File                                                                   hold member is included in your tax household only for the full months pre-
Form IND-HEALTH, along with the Shared Responsibility Worksheet, must           ceding the month in which the passing occurs. 
be filed if all of the following apply:                                          
• You are filing a Form RI-1040 or RI-1040NR.                                   Use Coverage Exemption Code “H2” for the month in which the death oc-
• You cannot be claimed as a dependent by another taxpayer.09/08/2023curred and for the months following for the rest of the year. 
• For one or more months of 2023, you or someone else in your tax                
household did not have minimum essential coverage.                              For example, if a member of the tax household passes away in May of 2023, 
                                                                                you would enter “H2” for the months of May through December on Form 
Use Form IND-HEALTH to report or claim a coverage exemption if you can          IND-HEALTH. 
claim any part-year exemptions or exemptions for specific members of your        
tax household. This will reduce the amount of your shared responsibility pay-    
ment.                                                                           CHILD    
                                                                                Means any individual under the age of eighteen (18).  
Not required to file a tax return                                                
If you are not required to file a tax return, your tax household is exempt from For the purposes of minimum essential coverage and for calculating the 
the shared responsibility payment and you do not need to file a tax return to   shared responsiblity payment, a dependent under the age of eighteen (18) 
claim the coverage exemption. However, if you are not required to file a tax    on January 1st of the calendar year is considered a child for the entire cal-
                                                                                endar year.  
                                                              Page IND-1

- 2 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet
COVERAGE EXEMPTION CODES AND REASONS c. Plans in the individual market. Coverage under a health plan of-
Page IND-9 of these Instructions includes a chart of coverage exemptions fered in the individual market within a state.
allowed under 26 U.S. Code § 5000A(e). In addition to those exemptions d. Grandfathered health plan. Coverage under a grandfathered
allowed under 26 U.S. Code § 5000A(e), the chart includes other valid cir- health plan.
cumstances in which a member of your tax household may be exempt e. Other coverage. Such other health benefits coverage, such as a
from minimum essential coverage requirements. state health benefits risk pool, as the federal Secretary of Health
and Human Services, in coordination with the Secretary of the Treas-
These Coverage Exemptions, if applicable, may be used to reduce your ury, recognizes for purposes of this subsection.
Shared Responsibility Payment.
2. Eligible employer-sponsored plan.
The Coverage Exemption Reasons are: The term "eligible employer-sponsored plan" means, with respect to any
Income Below the Filing Threshold employee, a group health plan or group health insurance coverage offered
Coverage Considered Unaffordable by an employer to the employee which is:
Short Coverage Gap a. A governmental plan (within the meaning of the Public Health Serv-
Citizens Living Abroad & Certain Noncitizens ice Act, 42 U.S.C. § 300gg-91(d)(8)), or
Members of a Healthcare Sharing Ministry b. Any other plan or coverage offered in the small or large group mar-
Minimum Essential Health Coverage ket within a state.
Incarceration c. Such term shall include a grandfathered health plan described in §
Aggregate Self Only Coverage Considered Unaffordable 15.6 (G)(1)(d) of this Part offered in a group market.
HealthSource RI Exemption
Member of Tax Household Born or Adopted During the Year 3.Excepted benefits not treated as minimum essential coverage.
Member of Tax Household Died During the Year The term "minimum essential coverage" shall not include health insurance
coverage which consists of coverage of excepted benefits:
a. Described in the Public Health Service Act, 42 U.S.C. § 300gg-
DEPENDENT 91(c)(1); or
An individual who is or may become eligible for minimum essential cover- b. Described in the Public Health Service Act, 42 U.S.C. § 300gg-
age under the terms of a health insurance plan because of a relationship 91(c)(2), (3) or (4) if the benefits are provided under a separate pol-
to a qualified individual or enrollee. icy, certificate, or contract of insurance.

4. Individuals residing outside United States or residents of territo-
ries.
DEPENDENTS OF MORE THAN ONE TAXPAYER Any applicable individual shall be treated as having minimum essential
Your tax household does not include someone you can, but do not, claim as coverage for any month:
a dependent if the dependent is properly claimed on another taxpayer's re- a. If such month occurs during any period described in 26 U.S.C. §
turn. 911(d)(1)((A)) or ((B)) which is applicable to the individual, or
b. If such individual is a bona fide resident of any possession of the
United States (as determined under 26 U.S.C. § 937(a)) for such
HOUSEHOLD INCOME month.
Your household income is your modified adjusted gross income (MAGI)
plus the MAGI of each individual in your tax household whom you claim as
a dependent if that individual is required to file a tax return because his or
her income meets the income tax return filing threshold. MODIFIED ADJUSTED GROSS INCOME
Modified Adjusted Gross Income (“MAGI’) is determined by adding to your
federal adjusted gross income any amount excluded from gross income
MINIMUM ESSENTIAL COVERAGE under section 911, and any amount of interest received or accrued by the
“Minimum essential coverage” has the same meaning as set forth in 26 DRAFT taxpayer during the taxable year which is exempt from tax.
U.S.C § 5000A(f), as in effect on December 15, 2017:
See page IND-6 of these instructions for tables to assist you in calculating
1. In general. the MAGI for your tax household.

The term "minimum essential coverage" means any of the following:
a. Government sponsored programs. Coverage under:
(1) The Medicare program under the Social Security Act, 42 PART YEAR RESIDENT
U.S.C. § 1395(c) et seq., An individual who is a Rhode Island resident as defined in R.I. Gen. Laws
(2) The Medicaid program under the Social Security Act, 42 § 44-30-5 for less than the full calendar year is only required to maintain
U.S.C. § 1396 et seq., minimum essential health coverage for those months as a Rhode Island
(3) The CHIP program under the Social Security Act, 42 U.S.C. resident.
§ 1397(aa) et seq.,
(4) Medical coverage under 10 U.S.C. § 1071 et seq., including A part year resident should enter Coverage Exemption Code “N’ for those
coverage under the TRICARE program; 09/08/2023months during which he or she was not a resident of Rhode Island as well
(5) A health care program under 38 U.S.C. §§ 1701 et seq. or as the month in which the individual either became or ceased to be a
1801 et seq., as determined by the Secretary of Veterans Af- Rhode Island resident.
fairs, in coordination with the Secretary of Health and Human
Services and the Secretary of the Treasury, For example, a member of your tax household moves to the state of
(6) A health plan under 22 U.S.C. § 2504(e) (relating to Peace Alaska in September of 2023, you would enter “N” for the months of Sep-
Corps volunteers); or tember through December for that tax household member on Form IND-
(7) The Nonappropriated Fund Health Benefits Program of the HEALTH.
Department of Defense, established under the National Defense
Authorization Act for Fiscal Year 1995, 10 U.S.C. § 1587 (1995) Individuals residing outside United States or residents of territories.
note. Any applicable individual shall be treated as having minimum essential
b. Employer-sponsored plan. Coverage under an eligible employer- coverage for any month:
sponsored plan. a. If such month occurs during any period described in 26 U.S.C. §
911(d)(1)((A)) or ((B)) which is applicable to the individual, or
Page IND-2

- 3 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet
b. If such individual is a bona fide resident of any possession of the Single gap in coverage for three or more consecutive months
United States (as determined under 26 U.S.C. § 937(a)) for such Eddie had coverage each month until September. This left Eddie without
month. coverage for three months - October, November and December. Because
Eddie did not have minimum essential coverage for three or more consec-
utive months,not he is eligible for the Short Coverage Gap exception.
SHARED RESPONSIBILITY PAYMENT PENALTY
Tax assessed when a taxpayer fails to maintain minimum essential cover- Multiple gaps in coverage
age for each month of the calendar year Teddy had coverage for every month except February, March, October,
and November. Teddy is eligible for the short coverage gap exemption
only for February and March. Teddy would enter “B” for the months of Feb-
SHORT COVERAGE GAP ruary and March only, and would be subject to the Shared Responsibility
You generally can claim a coverage exemption for yourself or another Payment Penalty for the months of October and November.
member of your tax household for each month of a gap in coverage of less
than 3 consecutive months. If an individual had more than one short cov-
erage gap during the year, the individual is exempt only for the month(s) in Code “C” = Citizens Living Abroad and Certain Noncitizens
the first gap. If an individual had a gap of 3 months or more, the individual
is not exempt for any of those months. You can claim a coverage exemption for yourself or another member of
your tax household to which any of the following apply.

TAX HOUSEHOLD The individual is a U.S. citizen or a resident alien who is physically
For purposes of Form IND-HEALTH, your tax household generally includes present in a foreign country (or countries) for at least 330 full days
you, your spouse (if filing a joint return), and any individual you claim as a during any period of 12 consecutive months. You can claim the cover-
dependent on your tax return. It also generally includes each individual you age exemption for any month during your tax year that is included in
can, but do not, claim as a dependent on your tax return. the 12-month period. For more information, see Physical Presence
Test in Pub. 54.

The individual is a U.S. citizen who is a bona fide resident of a foreign
COVERAGE EXEMPTION DESCRIPTIONS country (or countries) for an uninterrupted period which includes the
entire tax year. You can claim the coverage exemption for the entire
year. For more information, see Bona Fide Residence Test in Pub.
54.
Code “A” = Coverage Considered Unaffordable
The individual is a resident alien who is a citizen or national of a for-
You can claim a coverage exemption for yourself or another member of eign country with which the U.S. has an income tax treaty with a
your tax household for any month in which: nondiscrimination clause and who is a bona fide resident of a foreign
country for an uninterrupted period that includes the entire tax year.
1 The individual is eligible for coverage under an employer plan and You can claim the coverage exemption for the entire year. For more
that coverage is considered unaffordable, or information, see Bona Fide Residence Test in Pub. 54.
2 The individual isn’t eligible for coverage under an employer plan and
the coverage available for that individual through the Marketplace is · The individual is a bona fide resident of a U.S. territory. You can claim
considered unaffordable. the coverage exemption for the entire year.
3 Coverage is considered unaffordable if the individual's required con-
tribution (described later) is more than 8.17% (0.0817) of household The individual isn’t lawfully present in the U.S. and isn’t a U.S citizen
income. or U.S. national. For this purpose, an immigrant with Deferred Action
DRAFT for Childhood Arrivals (DACA) status is not considered lawfully pres-
Use the Affordability Worksheet on page IND-10 to help you determine if ent and therefore qualifies for this exemption. For more information
coverage is considered unaffordable for one or more months throughout about who is treated as lawfully present for purposes of this coverage
the year for yourself or another family member allowing you to use Code exemption, visit www.HealthCare.gov.
“A” for that month(s).
The individual is a nonresident alien, including (1) a dual-status alien
in the first year of U.S. residency and (2) a nonresident alien or dual-
Code “B” = Short Coverage Gap status alien who elects to file a joint return with a U.S. spouse. You
can claim the coverage exemption for the entire year. This exemption
You generally can claim a coverage exemption for yourself or another doesn't apply if you are a nonresident alien for 2023, but met certain
member of your tax household for each month of a gap in minimum es- presence requirements and elected to be treated as a U.S. resident.
sential coverage of less than three (3) consecutive months. If an individual For more information, see Pub. 519.
had more than one short coverage gap during the year, the individual is
exempt only for the month(s) in the first gap. If an individual09/08/2023had a gap of
three (3) months or more, the individual is not exempt for any of those Code “D” = Members of a Health Care Sharing Ministry
months.
You can claim a coverage exemption for yourself or another member of
For example: your tax household for any month in which the individual was a member of
Single gap in coverage less than three consecutive months a health care sharing ministry for at least one (1) day in the month.
Ruth had coverage from her employer for her and her spouse for every
month through July. Her spouse was able to sign up for coverage for Use Coverage Exemption Code "D" for the months which apply.
them, but the coverage was not effective until October. Because they
were only without coverage for the months of August and September, Ruth In general, a health care sharing ministry is a tax-exempt organization
and her spouse are eligible for the short coverage gap exemption for the whose members share a common set of ethical or religious beliefs and
months of August and September. Ruth and her spouse would each enter share medical expenses in accordance with those beliefs, even after a
“B” for the months of August and September. member develops a medical condition. For you to qualify for this exemp-
Page IND-3

- 4 -

 Individual Health Insurance Mandate for Rhode Island Residents 
                  Individual Health Insurance Form and Shared Responsibility Worksheet
tion, the health care sharing ministry (or a predecessor) must have been in         the entire year.  
existence and sharing medical expenses continuously and without inter-               
ruption since December 31, 1999. An individual who is unsure whether a              Use Coverage Exemption Code "G1” for you and your household mem-
ministry meets the requirements should contact the ministry for further in-         bers for the entire year if you are eligible for this coverage exemption. 
formation.                                                                           
                                                                                     
                                                                                                Code “H1” = Member of Tax Household Born  
      Code “E” = Members of Indian Tribes or Individuals                                                or Adopted During the Year 
        Otherwise Eligible for Services from an Indian                               
                        Health Care Provider                                        Your tax household for a month only includes individuals who were alive 
                                                                                    for the entire month. In general, if an individual was added to your tax 
You can claim a coverage exemption for yourself or another member of                household by birth or adoption and that individual had minimum essential 
your tax household for any month in which the individual was a member of            coverage, you do not need to file Form IND-HEALTH solely to report that 
a federally recognized Indian tribe, including an Alaska Native Claims Set-         fact.  
tlement Act (ANCSA) Corporation Shareholder (regional or village), for at            
                                                                                    For example, if all members of your tax household, as well as the newborn 
least 1 day in the month. The list of village or regional corporations formed       or adopted individual, had minimum essential coverage for every month of 
under ANCSA is available at:                                                        the year they are part of your tax household and residents of Rhode Is-
https://www.ncsl.org/research/state-tribal-institute/list-of-federal-and-state-     land, check the “Full-year health care coverage” box on Form RI-1040, 
recognized-tribes.aspx                                                              line 12b or Form RI-1040NR, line 15b.   You do not need to file Form IND-
                                                                                    HEALTH.   
You also can claim a coverage exemption for yourself or another member               
of your tax household for any month in which the individual was eligible for        However, if you had or adopted a child during 2023 and you are claiming a 
services through an Indian health care provider or through the Indian               coverage exemption (other than code “H1”) for one or more months on 
Health Service.                                                                     Form IND-HEALTH, you can claim a coverage exemption for that child for 
                                                                                    the months before (and including) the month when the child was born or 
Use Coverage Exemption Code "E" for the months which apply.                         adopted.  
                                                                                     
                                                                                    To claim this coverage exemption, enter code “H1” for the month in which 
                     Code "F" = Incarceration                                       the child was born or adopted and the months preceding that month to the 
                                                                                    beginning of the year. 
You can claim a coverage exemption for yourself or another member of                 
your tax household for any month in which the individual was incarcerated           For example, Jamison was born in September.  His parents did not have 
for at least one (1) day in the month. For this purpose, an individual is con-      minimum essential coverage for any of 2023.  When Jamison’s parents 
sidered incarcerated if he or she was confined, after the disposition of            complete Form IND-HEALTH, code “H1” would be entered for Jamison for 
charges, in a jail, prison, or similar penal institution or correctional facility.  the months of January through September.  October, November and De-
                                                                                    cember would be left blank.  
Use Coverage Exemption Code "F" for the months in which the individual               
was incarcerated.                                                                   In addition, if Jamison was born in October rather than September, when 
                                                                                    Jamison’s parents complete Form IND-HEALTH, code “H1” would be en-
For example, if the individual was incarcerated from March 24 until June 1,         tered for Jamison for the months of January through October and code “B” 
enter “F” for the months of March through June on Form IND-HEALTH.                  would be entered for the months of November and December.  Even 
                                                                                    though Jamison’s parents cannot claim the Short Coverage Gap (code “B’) 
See Code “X” on page IND-5 if there was a time period when the house-               exemption, they can claim it for their newborn child. 
hold member had minimum essential coverage for the months prior to or                
after incarceration.                      DRAFT 
                                                                                                Code “H2” = Member of Tax Household  
                                                                                                            Died During the Year 
        Code “G1” = Aggregate Self-only Coverage                                                                         
                     Considered Unaffordable                                        Your tax household for a month only includes individuals who were alive 
                                                                                    for the entire month. In general, if a member of your tax household died 
You and any other members of your tax household you list on your 2023               during the year, you do not need to file Form IND-HEALTH solely to report 
tax return (such as yourself, your spouse if filing jointly, and your depend-       that fact.  
ents) who can't be claimed as a dependent on someone else's 2023 tax                 
return can claim a coverage exemption for all months in 2023 if, for at             For example, if all members of your tax household, including the decedent 
least one month in 2023, all of the following conditions apply:                     prior to death, had minimum essential coverage for every month they are 
                                                                                    part of your tax household and residents of Rhode Island, check the “Full-
1) The cost of self-only coverage through employers for two or more mem-            year health care coverage” box on Form RI-1040, line 12b or Form RI-
bers of your tax household doesn't exceed 8.17% of household09/08/2023income        1040NR, line 15b.   You do not need to file Form IND-HEALTH.   
when tested individually,                                                            
                                                                                    However, if a member of your tax household died during 2023 and you are 
2) The cost of family coverage that the members of your tax household de-           claiming a coverage exemption (other than code “H2”) for one or more 
scribed in condition 1 could enroll in through an employer exceeds 8.17%            months on Form IND-HEALTH, you can claim a coverage exemption for 
of household income,    and                                                         the months following (and including) the month of his or her death.  
                                                                                     
3) The combined cost of the self-only coverage identified in condition 1            To claim this coverage exemption, enter code “H2” for the month in which 
exceeds 8.17% of household income.                                                  the household member passed away along with the months through the 
                                                                                    end of the year. 
If you meet the requirements just described, you and any other members               
of your tax household that you list on your 2023 tax return who can't be            For example, Nick did not have minimum essential coverage from January 
claimed as dependents on someone else's 2023 tax return are exempt for              through April.  Nick had coverage starting in May and until he passed 
                                                                         Page IND-4

- 5 -

 Individual Health Insurance Mandate for Rhode Island Residents 
                  Individual Health Insurance Form and Shared Responsibility Worksheet
away in July.  When Form IND-HEALTH is completed for the tax house-          mum threshold required for filing a tax return for tax year 2023, enter Cov-
hold which Nick is a part of, no code would be entered in January through    erage Exemption Code “NC” for each month and for each household 
April; May and June would have code “X” and the rest of the year would       member on Form IND-HEALTH. 
have code “H2”.                                                                                                  
                                                                                                                 
                                                                                     Code “X” = Minimum Essential Health Coverage 
            Code “N” = Nonresident During the Year                            
                                                                             If you and each member of your tax household had minimum essential 
An individual who is a Rhode Island resident as defined in R.I. Gen. Laws    health coverage for each month of tax year 2023, you should check the 
§ 44-30-5 for less than the full calendar year is only required to maintain  box on Form RI-1040, line 12b or Form RI-1040NR, line 15b to indicate 
minimum essential health coverage for those months during which the in-      your tax household had minimum essential health coverage for the whole 
dividual is a Rhode Island resident.                                         year.  You will not complete Form IND-HEALTH. 
                                                                              
                                                                             If, at some point during tax year 2023, you or a member of your household 
Part-year Resident of Rhode Island:                                          did not have minimum essential coverage, you should enter Coverage Ex-
A part-year resident who, along with all members of his/her tax household    emption Code “X” for those months in which you and other members of 
had minimum essential coverage for all of the months when they were          your tax household DID have minimum essential health coverage.     
Rhode Island residents, does not need to file Form IND-HEALTH.  Instead,      
the box on RI-1040NR, line 15b will be checked.                              You are considered to have minimum essential coverage for a month if 
                                                                             you have that coverage for at least one (1) day during that month. 
A part year resident who, along with all members of his/her tax household 
did not maintain minimum essential coverage for all of the months when        
they were Rhode Island residents, should enter Coverage Exemption                                                
Code “N’ for those months during which he or she was not a resident of                 Code “RI” = HealthSource RI Exemption 
Rhode Island as well as the month in which the individual either became                                          
or ceased to be a Rhode Island resident.                                     HealthSource RI will be accepting applications from Rhode Islanders who 
                                                                             may be exempt from the Shared Responsibility Payment.  You may apply 
For example, a member of your tax household moves to the state of            for an exemption from HealthSource RI for the following categories: 
Alaska in September of 2023.  During the months prior to September the        
household member had minimum essential coverage from January until            
May. You would enter “N” for the months of September through December        Members of Certain Religious Sects 
for that tax household member on Form IND-HEALTH.                            Members of certain religious sects (enter ECN). An individual may claim a 
                                                                             coverage exemption for members of recognized religious sects only if the 
See Code “X” in the next column for the time period when the household       Marketplace has granted the individual an exemption.  
member had minimum essential coverage prior to moving out of state.           
                                                                             Hardship Affecting Ability to Purchase Coverage 
Nonresident of Rhode Island:                                                 You can claim a coverage exemption for yourself or another member of 
A full-year nonresident is not subject to Rhode Island’s requirement to      your tax household for 2023 if you experienced a hardship that prevented 
maintain minimum essential health coverage.  The full-year nonresident       you from obtaining minimum essential coverage. Hardship exemptions 
will not complete Form IND-HEALTH and will  notcheck the “Full-year          usually cover the month before the hardship, the months of the hardship, 
health care coverage” box on Form RI-1040NR.                                 and the month after the hardship.  
                                                                              
                                                                             Hardships can include: 
         Code “NC” = Income Below Filing Threshold                           Being homeless; 
                                                                             Being evicted or facing eviction or foreclosure; 
                                                                             Receiving a shut-off notice from a utility company; 
You qualify for this exemption if your household incomeDRAFTis less than the Experiencing domestic violence; 
amount of gross income requiring you to file a return as set forth in R.I.   Experiencing the death of a close family member; 
Gen. Laws  § 44-30-51.                                                       Experiencing a fire, flood, or other natural or human-caused disaster that 
                                                                             caused substantial damage to your property; 
First, determine your household income for the taxable year (see definition  Filing for bankruptcy; 
of Household Income on page IND-2).  Then compare your household in-         Having unreimbursed medical expenses in the last 24 months that re-
come to the state filing threshold that applies to you based on your filing  sulted in substantial debt; 
status and your dependents.                                                  Experiencing unexpected increases in necessary expenses due to caring 
                                                                             for an ill, disabled, or aging family member; 
If you qualify for this coverage exemption, everyone in your tax household   Your child was denied Medicaid and CHIP, and another person is required 
is exempt for the entire year.                                               by court order to provide coverage to the child; 
                                                                             Experiencing personal circumstances that create a hardship, such as 
Minimum filing threshold:                                                    when no affordable plans provide access to needed specialty care; or 
Standard Deduction Amounts:                          09/08/2023Experiencing a hardship not included in this list that prevented you from 
                               Single    $10,000                             getting health insurance. 
                    Married Joint    $20,050                                  
       Qualifying Widow(er)    $20,050                                       Use Coverage Exemption Code “RI” on Form IND-HEALTH for the months 
             Married Separate    $10,025                                     to which one of the above exemptions applies.  
          Head of Household    $15,050                                        
                                                                             You must apply to HealthSource RI for an exemption certificate.  You 
Exemption Amount: $4,700                                                     will need to enter the Exemption Certificate number on Form IND-
                                                                             HEALTH.   
Multiply the Exemption Amount above by the number of members you would        
claim on your personal income tax return and then add that to the applicable                                     
Standard Deduction Amount from the list above.                                                                   
 
If your gross income or the income of your household is less than the mini-                                      
                                                                          Page IND-5

- 6 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet
Code “M” = Member of tax household lost medicaid during If you have one or more dependents with:
the year
1) a filing requirement AND
If you or another memeber of your tax household had Medicaid during tax 2) you reported the dependent's income on Form 8814, you must include
year 2023, but lost coverage at some point during the year, you can claim each dependent's Modified AGI in the calculation of your household in-
a coverage exemption for yourself or another member of your tax house- come.

hold for any month in which the individual did not have Medicaid coverage. Using Table 2 below, enter the income amounts from Federal Form 8814
for each applicable dependent.
Use Coverage Exemption Code “M” for the months in which the individual
no longer had Medicaid coverage. For example, if the individual had Medi-
caid coverage until September 14, enter “M” for the months of September
through December on form IND-HEALTH. Table 2
Form 8814, line 1b.
Use Coverage Exemption Code “X” for the time period when the house-
hold member had minimum essential coverage under Medicaid. Form 8814, line 4 or 5, whichever is smaller.

Dependent’s Modified AGI.
MODIFIED AGI CALCULATION
If you do not have one or more dependents that meet the criteria requiring
Table 2 to be completed, you can enter the Modified AGI amount calcu-
lated above for ALL members of your tax household on line 4 of the
Modified Adjusted Gross income (Modified AGI). Shared Responsiblity Worksheet.
For purposes of Form IND-HEALTH and the Penalty Calculation Work-
sheet, your Modified AGI is your Adjusted Gross Income plus certain other
items from your tax return.
NOTE:
To determine your Modified AGI, enter the amounts from the Federal Form
1040 into Table 1 below. You will need to complete this table for ALL mem- The Modified Adjusted Gross Income amount to be used on the
bers of your tax household who were required to file Federal Form 1040 2023 Shared Responsiblity Worksheet - Individual Mandate Penalty
for tax year 2023. Calculation form MUST include the Modified AGI for each applicable
member of your tax household.

Table 1 Be sure to complete Table 1 for each applicable individual filing
his/her own Federal Form 1040, and Table 2 for each applicable de-
Form 1040, line 2a. pendent with income being claimed on Federal Form 8814 and in-
Form 1040, line 11. cluded in a household member’s Federal Form 1040.
Foreign earned income exclusion or Housing
exclusion from Form 2555, line 45.
Housing deduction from Form 2555, line 50.
Modified AGI. Total all of the above.
DRAFT

FORM IND-HEALTH LINE BY LINE INSTRUCTIONS
If you cannot check the "Full-year health care coverage” checkbox on page 1 of Form RI-1040 or RI-1040NR, Form IND-HEALTH and the Shared Respon-
sibility Worksheet must be completed and attached to your RI-1040 or RI-1040NR.

Form IND-HEALTH is used to list each member of your tax household and the months of minimum essential coverage, coverage exemption
and non-coverage.

Each member of your tax household is to be listed separately in one of the sections. Complete additional Form(s) IND-HEALTH as needed.
09/08/2023
Complete each section of Form IND-HEALTH with information for a member of your tax household.
Name: Enter this household member’s name.
Social security number: Enter this household member’s social security number.
Checkbox: If this household member was under the age of eighteen as of January 1, 2023, check the box.
Exemption number: If an individual qualified for an exemption through HealthSource RI, enter the exemption number(s) in the space provided.

In the section where the months of the year are shown, you will either enter one of the Coverage Exemption Codes from the reference chart on page
IND-9 for each corresponding month in which the household member had minimum essential health coverage or a coverage exemption. If an exemption
did not apply, leave the corresponding months blank.

Number of months for which an exemption did not apply: In each household member’s section, enter the number of months that are blank and do not
contain a coverage exemption code.

Page IND-6

- 7 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet
For example:
John Jones moved to Rhode Island in March. He did not have any health insurance until he found a full-time job in August. From that point on, John
had minimum essential coverage.

Name:
JOHN JONES Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Social Security Number: Checkü if under
18 years of age N N N X X X X X
123-45-6789
as of 01/01/2023

Exemption Number: Number of months for which an exemption did not apply. 4

Do this for each member of your tax household. Once this is done, you will need to add up the total number of months during which the adult (over the
age of 18) and child (under the age of 18 as of January 1, 2023) members of your tax household did not have minimum essential health coverage or a
coverage exemption.

For all of the adult members of your household - find those household members that do not have the under 18 years of age checkbox checked and
add the number of months from lines 1 through 5 in which these adult members of your tax household did not have minimum essential health coverage
or a coverage exemption.

Enter this number on line 6a on the bottom of Form IND-HEALTH and on line 1a of the Shared Responsibility Worksheet.

For all of the child members of your household - find those household members that have the under 18 years of age checkbox checked and add the
number of months from lines 1 through 5 in which these child members of your tax household did not have minimum essential health coverage or an ex-
emption.

Enter this number on line 6b on the bottom of Form IND-HEALTH and on line 1c of the Shared Responsibility Worksheet.

SHARED RESPONSIBILITY WORKSHEET

GENERAL INFORMATION
The Shared Responsibility Payment is determined by comparing the results of three different calculations listed below and taking the
higher of percentage of income method OR the Flat Dollar Method (but not to exceed the Average Bronze Plan amount).

Percentage of Income Method - 2.5 % of your Modified Adjusted Gross Income above the tax filing threshold.

Flat Dollar Amount Penalty - The maximum penalty amount is $2,085 (300% of the flat dollar amount penalty).

Average Bronze Plan amount as determined by HealthSource RI. For calendar year 2023, the Average Bronze Plan amount is
$350 per month.
DRAFT
LINE BY LINE INSTRUCTIONS

Line 1d - Children No Coverage Penalty
Multiply line 1c by $28.96.
STEP 1: FLAT FEE METHOD
Line 2 - Penalty Total Based on Calculations
Add the amounts from lines 1b and 1d.
Line 1 - Enter the number of months that members of the
household DID NOT HAVE coverage or an exemption Line 3 - Flat Fee Method Penalty
Enter amount from line 2 or the Maximum Flat Fee Penalty (using the Flat
For tax year 2023, the Monthly Penalty Rates are: Fee Method Worksheet located on the bottom of page IND-8), whichever
Adult $57.92 09/08/2023is less.

Child* $28.96
*Child is an individual under 18 years of age as of January 1.
STEP 2: PERCENTAGE OF INCOME METHOD
Line 1a - Total number of months without coverage or an exemption for all
adults in the household. This number can be found in box 6a of Form IND-
HEALTH.
Line 4 - Modified Adjusted Gross Income
Line 1b - Adult No Coverage Penalty. Multiply line 1a by $57.92. Using the table(s) on page IND-6 of these instructions enter your Modified
Adjusted Gross Income. If married filing separately and living in the same
Line 1c - Total number of months without coverage or an exemption for all household, each spouse must combine their income figures from their
children. This number can be found in box 6b of Form IND-HEALTH. separate returns when completing this section. If you have no filing re-
quirement enter zero.
Page IND-7

- 8 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet
Line 5 - Federal Standard Deduction Line 12 - Multiply line 11 by line 7.
Using the chart below, enter your Federal Standard Deduction from Fed-
eral Form 1040. Line 13 - Enter the amount from line 3 or line 12, whichever is greater.

Federal Standard Deduction for tax year 2023:
Married Filing Jointly $27,700 STEP 3: BRONZE PLAN METHOD
Married Filing Separately $13,850
Head of Household $20,800
Single $13,850
Qualifying surviving spouse $27,700 Line 14a - Enter the number of months subject to the penalty from line 10
of the worksheet.
If you and your spouse file married filing separately and living in the same
household, each spouse must combine their deductions from their sepa- Line 14b - Multiply the number of months from line 14a times $350 and
rate returns when completing this section. enter the total here.

Line 6 - Subtract the Federal Standard Deduction amount on line 5 of the Note: For tax year 2023, the average monthly bronze plan amount
worksheet from your Modified Adjusted Gross Income on line 4 of the was $350.
worksheet.
Line 14c - Household Amounts
Use the list provided to find the number of total household members that
Line 7 - Income Percentage Amount applies to your household and enter the corresponding dollar amount.
Multiply the amount on line 6 by 2.5% (0.025). This amount represents the Average Bronze Plan annual amount.

Line 8 - Household Size Number of Household members Amounts
Enter the total number of members in your household, including yourself, 1 $4,200
your spouse (if living in the same household at any point during the year) 2 $8,400
and any dependents as claimed on Form IND-HEALTH. 3 $12,600
4 $16,800
NOTE: All members should be listed on the Individual Mandate schedule. 5 or More $21,000
If you need more space, complete an additional Form IND-HEALTH.
Line 14d - Enter the amount from line 14b or line 14c, whichever is less.
Line 9 - Number of Household Periods
Multiply the number of household members from line 8 by 12.0. Line 15 - Individual Mandate Fee
Enter the amount from line 13 or line 14d, whichever is less.
Line 10 - Months Subject to Penalty Enter this amount on Form RI-1040, page 1, line 12b or Form RI-1040NR,
Add the total number of months of no health coverage or no exemption for page 1, line 15b.
all adults from line 1a and the total number of months of no health cover-
age or no exemption for all children under the age of 18 from line 1c.

Line 11 - Uninsured/unexempted Apportionment Ratio
Divide line 10 by line 9. Carry apportionment to four decimal places
(0.0000).

For example, if there are two adult members and two children in your tax
household, line 9 would be 48 (4 household members times 12). If you DRAFT
lost your health coverage in August of 2023, line 10 would be 16 (4 house-
hold members times 4 months). 1648/ = 0.2500

FLAT FEE METHOD WORKSHEET

Complete lines 1 and 3 of the Flat Fee Method Worksheet using the information from Form IND-HEALTH
Flat Fee Method Worksheet Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
1. For each month, enter the number of ADULTS
without coverage or an exemption
2. For each month, multiply the number of ADULTS 09/08/2023
times $695
3. For each month, enter the number of CHILDREN
without coverage or an exemption
4. For each month, multiply the number of
CHILDREN by $347.50
5. For each month, add lines 2 and 4
6. For each month, enter the amount from line 5 or
$2,085, whichever is less
7. Enter the total of all of the amounts on line 6......... $
8. Maximum Flat Fee Penalty: Divide line 7 by 12.0.. $

Page IND-8

- 9 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet

Types of Coverage Exemptions
This chart shows all of the coverage exemptions available for tax year 2023, including information about each exemption and the code
that is to be used on Form IND-HEALTH when you claim the exemption. If your coverage exemption was granted by HealthSource RI,
you will need to enter the Exemption Certificate Number (ECN) provided by HealthSource RI on Form IND-HEALTH.
These Coverage Exemption Reasons and Codes are also listed on the top of Form IND-HEALTH for easy reference.
Exemption
Coverage Exemption Reasons
Code
Income Below Filing Threshold:
Your gross income or your household income was less than your applicable minimum threshold for filing a tax return. NC
Coverage Considered Unaffordable:
The required contribution is more than 8.17% of your household income. A
Short Coverage Gap:
You went without coverage for less than 3 consecutive months during this year. B
Citizens Living Abroad and Certain Noncitizens:
You were:
- A U.S. citizen or a resident alien who was physically present in a foreign country or countries for at least 330 full
days during any period of 12 consecutive months.
- A U.S. citizen who was a bona fide resident of a foreign country or countries for an uninterrupted period that in-
cludes the entire tax year.
- A bona fide resident of a U.S. territory. C
- A resident alien who was a citizen or national of a foreign country with which the U.S. has an income tax treaty
with a nondiscrimination clause, and you were a bona fide resident of a foreign country for an uninterrupted period
that includes the entire tax year;
- Not lawfully present in the U.S. and not a U.S. citizen or U.S. national.
- A nonresident alien including (1) a dual-status alien in the first year of U.S. residency and (2) a nonresident alien
or dual-status alien who elects to file a joint return with a U.S. spouse.
Members of a Health Care Sharing Ministry:
You were a member of a health care sharing ministry. D
Members of Federally Recognized Indian Tribes:
You were either a member of a federally recognized Indian tribe or you were otherwise eligible for services through E
an Indian health care provider or the Indian Health Service.
Incarceration:
You were in jail, prison, or similar penal institution or correctional facility after the disposition of charges. F
Aggregate Self Only Coverage Considered Unaffordable:
Two or more family members’ aggregate cost of self-only employer-sponsored coverage was more than 8.17% of
household income, as was the cost of any availableDRAFTemployer-sponsored coverage for the entire family. G1
Member of Tax Household Born or Adopted During the Year:
The months before and including the month that the individual was added to your tax household by birth or adop-
H1
tion. Claim this exemption only if you are also claiming another exemption or period of no coverage on Form IND-
HEALTH.
Member of Tax Household Died During the Year:
The months after the month that a member of your tax household died during the year. You should claim this ex- H2
emption only if you are also claiming another exemption period of no coverage on Form IND-HEALTH.
Nonresident of Rhode Island:
The months during which the individual was a resident of another state as well as the month in which the individual N
either became or ceased to be a Rhode Island Resident. Claim this exemption only if you are claiming another ex-09/08/2023
emption on Form IND-HEALTH or have a period of no coverage during your time as a Rhode Island resident.
Minimum Essential: Health Coverage
You had minimum essential health coverage for part of 2023. If you had minimum essential health coverage for the X
entire year, see Form RI-1040 or RI-1040NR instructions.
Healthsource:RI Exemption
An exemption you received through HealthSource RI for which you were provided a valid Exemption Certificate RI
Number.
Medicaid:
You had Medicaid during tax year 2023, but lost coverage at some point during the year. M

Page IND-9

- 10 -

Individual Health Insurance Mandate for Rhode Island Residents
Individual Health Insurance Form and Shared Responsibility Worksheet

Affordability Worksheet
for use with Code “A” = Coverage Considered Unaffordable

For help relating to questions about health insurance go to https://healthsourceri.com/affordability-sheet/.

Use this worksheet to determine whether coverage for each individual in your tax household is considered unaffordable allowing you to
use Exemption Code “A”.

An individual is eligible for the affordability exemption for any month in which the Required Contribution from (B), is more than the
Affordability Threshold from (A). To claim this coverage exemption, enter code “A” on Form IND-HEALTH for the month(s) to which the
exemption applies as determined below.

(A) Affordability Threshold
Enter 8.17% (0.0817) of your household income (see Household income) in the box to the
right. For this purpose, increase household income by the amount of any premium that is paid $
through a salary reduction arrangement and excluded from gross income.

(B) Required Contribution Amount
For each member of your tax household, enter in the columns provided the amount the individual must pay for coverage for the first
situation below that applies to that person. If the required contribution is the same for the whole year, enter the annual required contri-
bution in the space for each month.

Situations (use the first that applies to each member of your tax household, including you, for each month):
1. The lowest cost self-only policy offered to each member of your tax household by his or her employer.
2. The lowest cost family policy offered by your employer or your spouse's employer (if you are filing a joint return).
The policy must cover everyone in your tax household:
a Who you list on your 2023 tax return (such as yourself, your spouse if filing jointly, and your dependents) and who cannot
be claimed as a dependent on someone else’s 2023 tax return,
b Who isn't eligible for other employer coverage, and
c Who doesn't qualify for another coverage exemption.
3. The amount from the Marketplace Coverage Affordability Worksheet.

For each individual, coverage is considered unaffordable and the individual is exempt for any month in which the Required Contribution
Amount is more than the Affordability Threshold.

Member(s) of your tax household.Enter one name per column.

Annualized required contribution for: DRAFT

January
February
March
April
May
June

July 09/08/2023
August
September
October
November
December

Page IND-10

- 11 -

Individual Health Insurance Mandate for Rhode Island Residents 
           Individual Health Insurance Form and Shared Responsibility Worksheet

               Marketplace Coverage Affordability Worksheet 
               for use with Code “A” = Coverage Considered Unaffordable 

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 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.  For reference tables 
related to health insurance premiums and plans and for help relating to questions on health coverage go to: 
https://healthsourceri.com/affordability-sheet/. 

                                           DRAFT 

                                                 09/08/2023

Footnotes: 
1 – Figure the nontaxable social security benefits received by that individual by subtracting Federal Form 1040, line 6b from Federal Form 
1040, line 6a. 
2 – If the result is less than 1.38 and you meet the Medicaid eligibility requirements, you are eligible for Medicaid and therefore not eligible for a 
premium tax credit. Enter -0- on line 10.  
                                                 Page IND-11

PDF file checksum: 383695789

(Plugin #1/9.12/13.0)