Individuals are exempt from purchasing insurance if their income is below the tax-filing threshold (in 2020, this amount was \($12,200\) for single people younger than 65 years and \($24,400\) for couples younger than 65 years), the lowest-cost plan option exceeds 8.24% of their income in 2020, they qualify for a religious exemption, they are incarcerated, they are undocumented immigrants, they were without coverage for less than 3 months, they are Native Americans, or they qualify as having a hardship. Based on a June 2013 HHS rule, hardship exemptions must be granted for individuals who experience an event that resulted in an unexpected increase in expenses such that purchasing health insurance would make it impossible to pay for necessities, such as food and shelter. The rule cites circumstances that would be considered under this exemption:

homelessness, eviction, domestic violence, death of a close family member, bankruptcy, substantial recent medical debt, and disasters that substantially changed the individual’s property (Exchange Establishment Standards, 2012). Hardship exemptions are also allowed for individuals who would have qualified for Medicaid had their state chosen to expand the program under the ACA, and other exemptions exist based on projected low income (Jost, 2013). In 2018, the Trump administration created four new exemption categories (Center for Consumer Information and Insurance Oversight, 2018; HHS Notice of Benefit and Payment Parameters [HHS Benefit and Payment Rule], 2018). Individuals may apply for a hardship exemption if they (1) live in counties without marketplace plans, (2) live in counties with a single insurer, (3) object to abortion coverage, or (4) meet additional hardship circumstances, such as needing specialty care from out-of-network providers (Andrews, 2018). Data from

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Andrews, M. (2018, April 24). 4 New exemptions to the tax penalty for lacking health insurance. NPR. https://www.npr.org/sections/health-shots/2018/04/24/605007498/4- new-exemptions-to-the-tax-penalty-for-lacking-health-insurance; Center for Consumer Information and Insurance Oversight, Centers for Medicare and Medicaid Services. (2018, April 9). Guidance on hardship exemptions from the individual shared responsibility provision for persons experiencing limited issuer options or other circumstances. https://www.cms.gov/CCIIO/Resources/Regulations-and- Guidance/Downloads/2018-Hardship-Exemption-Guidance.pdf; HHS Notice of Benefit and Payment Parameters for 2019. 83 Fed. Reg. 74, 16930-17071 (2018, April 17); and Exchange Establishment Standards and Other Related Standards Under the Affordable Care Act, 177 Fed. Reg. 11718, 2012.