Instructions For Schedule Hc - Health Care - 2012 (Page 5 of 10) in pdf

2012 Schedule HC — Line by Line Instructions

(d) Your financial circumstances were such that

You may also base your appeal on other circum-

Note: If you are filing an appeal, make sure you

the expense of purchasing health insurance would

stances, such as the application of the affordability

have calculated the penalty amount that you are

have caused you to experience a serious depriva-

tables in Schedule HC to you is inequitable (for ex-

appealing, but do not assess yourself or enter a

tion of food, shelter, clothing or other necessities.

ample, due to fluctuations in income or other

penalty amount on your income tax return.

changes in life circumstances that affect financial

(e) Your family size was so large that reliance on

If you (and/or your spouse, if married filing

status during the year), you were unable to obtain

the affordability schedule (see Table 3: Affordabil-

jointly) fill in that oval on your return, you will re-

government-subsidized insurance despite your in-

ity) to determine how much you could afford to

ceive a follow-up letter from the Connector Au-

come, or other circumstances that made you un-

pay for health insurance is inequitable.

thority asking you to state your grounds for appeal

able to purchase insurance despite your income.

in writing, and submit supporting documentation.

(f) During 2012 you purchased health insurance

If you file an appeal, you will be required to state

Failure to respond to that form within the time

that did not meet Minimum Creditable Coverage

your grounds for appealing, and provide further

specified will lead to dismissal of your appeal.

requirements, but which was close to or substan-

information and supporting documentation. Any

Also, you (and/or your spouse, if married filing

tially met those requirements, and you felt that

statements and claims you make will be under

jointly) are allowed only one opportunity to ap-

your circumstances prevented you from buying

pains and penalties of perjury.

peal. The Connector Authority will then review the

other insurance that met the requirements.

information you provided. You may be required to

(g) During 2012 you purchased health insurance

How to Appeal

participate in a hearing on your case. You will be

that did not meet Minimum Creditable Coverage

To appeal, you must fill in the oval for you (and

required to state your claims under pains and pen-

requirements because that is all that your employer

your spouse, if applicable) on Schedule HC, Ap-

alties of perjury.

offered, and you felt that your circumstances pre-

peals Section that authorizes DOR to share infor-

Note: Do not include any hardship documentation

vented you from buying other insurance that met

mation in your tax return, including Schedule HC,

with your original return. You will be required to

the requirements.

with the Commonwealth Health Insurance Connec-

submit substantiating hardship documentation at

tor Authority, the independent state body that will

a later date during the appeal process.

hear the appeal. No penalty will be assessed by

DOR pending the outcome of your appeal.

HC-5

Instructions For Schedule Hc - Health Care - 2012 Page 5

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