Rhode Island Individual Health Insurance Mandate Form

Individual Health Insurance Mandate Form
2023 IND-HEALTH
State of Rhode Island Division of Taxation

Form IND-HEALTH
23106299990101

Individual Health Insurance Mandate Form
Name

Social security number

Coverage Exemption Reasons and Codes
G1

A

Aggregate Self Only Coverage
Considered Unaffordable
Member of Tax Household Born
or Adopted During the Year

B

Member of Tax Household Died During the Year

H2

Citizens Living Abroad & Certain Noncitizens

C

Nonresident of Rhode Island

N

Members of Healthcare Sharing Ministry

D
E
F

Had Minimum Essential Health Coverage

X

HealthSource RI Exemption

RI
M

Income Below Filing Threshold

NC

Coverage Considered Unaffordable
Short Coverage Gap

Members of Indian Tribes
Incarceration

Medicaid

H1

Enter the name and social security number for each member of your tax household. For each household member, use the chart above to enter
an exemption code for each corresponding month in which the household member had minimum essential health coverage or an exemption. If
an individual qualified for an exemption through HealthSource RI, enter the exemption number(s) in the space provided.
Refer to the Individual Mandate Instructions for details and instructions on each of the coverage exemption types listed above.
If there are more than five (5) members in your tax household, please complete multiple IND-HEALTH Forms.

Name:
Social Security Number:

1)

Jan Feb Mar Apr May Jun
Check ü if under
18 years of age
as of 01/01/2023

Exemption Number:

Number of months for which an exemption did not apply:

Name:
Social Security Number:

2)

Jan Feb Mar Apr May Jun

Number of months for which an exemption did not apply:

Name:

3)

Jan Feb Mar Apr May Jun

Number of months for which an exemption did not apply:

Name:

4)

5)

Jul Aug Sep Oct Nov Dec

Check ü if under
18 years of age
as of 01/01/2023

Exemption Number:

Social Security Number:

Jul Aug Sep Oct Nov Dec

Check ü if under
18 years of age
as of 01/01/2023

Exemption Number:

Social Security Number:

Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun

Jul Aug Sep Oct Nov Dec

Check ü if under
18 years of age
as of 01/01/2023

Exemption Number:

Number of months for which an exemption did not apply:

Name:

Jan Feb Mar Apr May Jun

Social Security Number:

Exemption Number:

Jul Aug Sep Oct Nov Dec

Check ü if under
18 years of age
as of 01/01/2023

Number of months for which an exemption did not apply:

6a) Total periods that adults did not have coverage:

6b) Total periods that children did not have coverage: