Schedule Hc - Health Care Information - 2013

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FULL-YE R RESIDENTS ND CERT IN
P RT-YE R RESIDENTS MUST COMPLETE
ND ENCLOSE SCHEDULE HC WITH RETURN.
SOCIAL SECURITY NUMBER
FIRST NAME
M.I.
LAST NAME
Schedule H Health Care Information.
2013
You must enclose this schedule with Form 1 or Form 1-NR/PY.
c. Family size
1
a. Date of birth
b. Spouse’s date of birth
(see instructions)
2
Federal adjusted gross income (required information). If married filing separately,
0 0
see instructions (from U.S. Forms 1040, line 37; 1040A, line 21; or 1040EZ, line 4) . . . . . . . . . .
2
3
Indicate the time period that you were enrolled in a Minimum Creditable Coverage (MCC) health insurance plan(s). You must fill in an oval. The
Form MA 1099-HC from your insurer will indicate whether your insurance met MCC requirements. Note: MassHealth, Commonwealth Care,
Medicare, and health coverage for U.S. Military, including Veterans Administration and Tri-Care, meet the MCC requirements. If you did not
receive a Form MA 1099-HC from your insurer, or you had insurance that did not meet MCC requirements, see the section on MCC require-
ments in the instructions.
3a You:
Full-year MCC
Part-year MCC
No MCC/None
3b Spouse:
Full-year MCC
Part-year MCC
No MCC/None
Note: See instructions if, during 2013, you turned 18, you were a part-year resident or a taxpayer was deceased.
If you filled in “Full-year MCC” or “Part-year MCC”, go to line 4. If you filled in “No MCC/None”, go to line 6.
4
Indicate the health insurance plan(s) that met the Minimum Creditable Coverage (MCC) requirements in which you were enrolled in 2013, as
shown on Form MA 1099-HC (check all that apply). If you did not receive this form, fill in the oval in line(s) 4f and/or 4g and see instructions.
If you were enrolled in private insurance and MassHealth or Commonwealth Care, fill in the ovals, enter your private insurance information in
line(s) 4f and/or 4g and go to line 5.
4a Private insurance (complete lines 4f and/or 4g below). If more than two, complete Schedule HC-CS.
4a
You
Spouse
4b MassHealth or Commonwealth Care. Fill in oval(s) and go to line 5.
4b
You
Spouse
4c Medicare (including a replacement or supplemental plan). Fill in oval(s) and go to line 5.
4c
You
Spouse
4d U.S. Military (including Veterans Administration and Tri-Care). Fill in oval(s) and go to line 5.
4d
You
Spouse
4e Other government program (enter the program name(s) only in lines 4f and/or 4g below).
4e
You
Spouse
Note: Health Safety Net is not considered insurance or minimum creditable coverage.
4f
YOUR HEALTH INSURANCE.
Fill in if you were not issued Form MA 1099-HC
Complete if you answered line(s) 4a or 4e and go to line 5.
1. NAME OF PRIVATE INSURANCE COMPANY, ADMINISTRATOR OR OTHER GOVERNMENT PROGRAM (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SUBSCRIBER NUMBER (from Form MA 1099-HC)
2. NAME OF SECOND PRIVATE INSURANCE COMPANY, ADMINISTRATOR OR OTHER GOVERNMENT PROGRAM IF NECESSARY (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SUBSCRIBER NUMBER (from Form MA 1099-HC)
4g
SPOUSE’S HEALTH INSURANCE.
Fill in if you were not issued Form MA 1099-HC
Complete if you answered line(s) 4a or 4e and go to line 5.
1. NAME OF PRIVATE INSURANCE COMPANY, ADMINISTRATOR OR OTHER GOVERNMENT PROGRAM FOR SPOUSE (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SPOUSE’S SUBSCRIBER NUMBER (from Form MA 1099-HC)
2. NAME OF SECOND PRIVATE INSURANCE COMPANY, ADMINISTRATOR OR OTHER GOVERNMENT PROGRAM IF NECESSARY FOR SPOUSE (from box 1 of Form MA 1099-HC)
FEDERAL IDENTIFICATION NUMBER OF INSURANCE CO. (from box 2 of Form MA 1099-HC)
SPOUSE’S SUBSCRIBER NUMBER (from Form MA 1099-HC)
5
If you had health insurance that met MCC requirements for the full-year, including private insurance, MassHealth or Commonwealth Care,
you are not subject to a penalty. Skip the remainder of this schedule and continue completing your tax return.
If you had Medicare (including a replacement or supplemental plan), U.S. Military (including Veterans Administration and Tri-Care), or other
government insurance at any point during 2013, you are not subject to a penalty. Skip the remainder of this schedule and continue com-
pleting your tax return.
If you filled in the “Part-year MCC” or “No MCC/None” in line 3, you must complete line 6.
BE SURE YOU FILLED IN LINES 2 & 3 ABOVE. YOU MUST COMPLETE AND ENCLOSE SCHEDULE HC WITH YOUR RETURN.

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