Form FTB 3853 Health Coverage Exemptions and Individual Shared Responsibility Penalty

Use Form FTB 3853 to determine if you owe an individual shared responsibility penalty or to claim exemptions from the state individual health coverage mandate on your California state tax return. Use the California Franchise Tax Board forms finder to view Form FTB 3853.

You may be exempt from the individual mandate if your income is below the state tax filing threshold. Visit the California Franchise Tax Board (FTB) to see if you are exempt for this or other reasons.

Form FTB 3853 Health Coverage Exemptions and Individual Shared Responsibility Penalty and the Marketplace Coverage Affordability Worksheet

If health coverage was considered unaffordable for you or your family, you may qualify for an exemption from the individual mandate penalty through the FTB when you file your state income tax return. To claim this exemption on Form FTB 3853, you may need to calculate the lowest-cost Bronze plan and the second-lowest-cost Silver plan on the Marketplace Coverage Affordability Worksheet.

If instructed in Form FTB 3853 to complete the Marketplace Coverage Affordability Worksheet, follow the steps below to find the lowest-cost Bronze plan and the second-lowest-cost Silver plan available in your area:

Step 1: Go to Covered California’s Shop and Compare Tool.

Step 2: From the dropdown menu:

• Select the tax year in which you need information
• Enter your ZIP code (and county, if prompted)
• Enter your total household income for the tax filing year
• Enter the number of people in your tax household
• Enter the age of the head of household and other members of your tax household then select “Needs Coverage” for each member
  • Note: do not select the boxes for pregnant or blind or disabled for purposes of completing the FTB Marketplace Coverage Affordability Worksheet

  Step 3: Select "See My Results" after entering the information.

  Step 4: Select "Continue" after the pop up appears.

  Step 5: Select "Preview Plans."

  Step 6: Skip the screens, “Tell us about your health care needs,” by selecting "Next."

  Step 7: Select "View Plans."

  Step 8: Find the lowest-cost Bronze plan premium:

  • Use the “Sort By” menu and sort by Monthly Premium (low to high).
  • Use "Filter By" and scroll to "Metal Tier," then select "Bronze."
  • When sorted low to high, find the first Bronze plan on the screen.
  • Add together the monthly premium (the dollar amount in large black font) and the “after $[x] monthly savings” (the dollar amount in bold blue font). The sum of these amounts is the gross monthly premium for the lowest-cost Bronze plan.
  • Enter this number on Line 1 of the Marketplace Coverage Affordability Worksheet used for claiming an affordability exemption on your state tax return.

  Step 9: Find the second-lowest-cost Silver plan premium:

  • Use the "Sort By" menu and sort by Monthly Premium (low to high).
  • Use "Filter By" and scroll to "Metal Tier," then select "Silver" (make sure that Bronze is not also selected).
  • When sorted low to high, find the second Silver plan on the top row.
  • Add together the monthly premium (the dollar amount in large black font) and the “after $[x] monthly savings” (the dollar amount in bold blue font). The sum of these amounts is the gross monthly premium for the second-lowest-cost Silver plan.
  • Enter this number on Line 10 of the FTB Marketplace Coverage Affordability Worksheet used for claiming an affordability exemption on your state tax return.

  If you need help, please contact the Covered California Service Center. Representatives can help you calculate the gross premium amounts to use in the Marketplace Coverage Affordability Worksheet but cannot provide tax advice.