Instructions For Schedule Hc - Health Care - 2012 (Page 6 of 10) in pdf

2012

Schedule HC Worksheets and Tables

Below are the necessary worksheets you may need to complete your 2012 Schedule HC. Retain these worksheets for your records. Do n n o o t t submit

these with your tax return.

Schedule HC Worksheet for Line 6: Federal Poverty Level

Table 1: Federal Poverty Level,

1. Enter your federal adjusted gross income from Schedule HC, line 2 1

Annual Income Standards

2. Enter the income amount that corresponds to your family size (as

entered on Schedule HC, line 1c) from the 150% FPL column from

Family size*

150% FPL

Table 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

If line 1 is less than or equal to line 2, your income in 2012 was at or below 150% of the Federal Poverty

$16,764

Level and the penalty does not apply to you in 2012. Fill in the Yes oval in line 6 of Schedule HC, skip

$22,704

the remainder of Schedule HC and continue completing your tax return.

If line 1 is greater than line 2, your income in 2012 was above 150% of the Federal Poverty Level. Fill

$28,644

in the No oval in line 6 of Schedule HC and go to line 7 of Schedule HC.

$34,584

Schedule HC Worksheet for Line 10: Eligibility for Employer-Spon-

$40,524

sored Insurance That Met Minimum Creditable Coverage

The following worksheet will determine if you could have afforded employer-sponsored health insurance

$46,464

that met Minimum Creditable Coverage in 2012 (the employer’s Human Resources Department should

be able to provide this information to you). Complete only if you (and/or your spouse if married filing

$52,404

jointly) were eligible for insurance that met Minimum Creditable Coverage offered by an employer for

$58,344

the entire period you were uninsured in 2012 that covered you, and your spouse and dependent chil-

dren, if any. If an employer did not offer health insurance that met Minimum Creditable Coverage that

additional

+ $ 5,940

covered you, and your spouse and dependent children, if any, or if you were not eligible for insurance

that met Minimum Creditable Coverage offered by an employer, you were self-employed or you were

*This schedule reflects the Federal Poverty

unemployed, fill in the No oval(s) in line 10 of Schedule HC and complete the Schedule HC Worksheet

Level standards for 2012.

for Line 11 on page HC-7.

Note: If you answered Yes in line 6 of Schedule HC indicating that your income was at or below 150% of the Federal Poverty Level or you had three or fewer

blank ovals in a row during the period that the mandate applied on line 7 of Schedule HC, the penalty does not apply to you. Do not complete this work-

sheet. Skip the remainder of Schedule HC and continue completing your return. Be sure to enclose Schedule HC with your return.

If an employer offered you free health insurance coverage in 2012 that met Minimum Creditable Coverage (the employer’s Human Resources Department

should be able to provide this information to you), you are deemed able to afford health insurance and are subject to a penalty. Fill in the Yes oval(s) in

line 10 of Schedule HC and go to the Health Care Penalty Worksheet on page HC-9.

1. Enter your federal adjusted gross income from U.S. Form 1040, line 37; Form 1040A, line 21; or 1040EZ, line 4 . . . . . . . . . 1

If line 1 is less than or equal to: $16,764 if single or married filing separately with no dependents; $22,704 if married filing jointly with no dependents or

head of household/married filing separately with one dependent; or $28,644 if married filing jointly with one or more dependents or head of household/mar-

ried filing separately with two or more dependents, you are deemed unable to afford employer-sponsored health insurance that met Minimum Creditable

Coverage requiring an employee contribution. Fill in the No oval(s) in line 10 of Schedule HC. Skip the remainder of this worksheet and go to the Schedule

HC Worksheet for Line 11 on page HC-7.

If line 1 is more than: $56,273 if single or married filing separately with no dependents; $89,032 if married filing jointly with no dependents or head of

household/married filing separately with one dependent; or $119,270 if married filing jointly with one or more dependents or head of household/married filing

separately with two or more dependents, you are deemed able to afford employer-sponsored health insurance that met Minimum Creditable Coverage and

are subject to a penalty. Fill in the Yes oval(s) in line 10 of Schedule HC and go to the Health Care Penalty Worksheet on page HC-9.

If line 1 is more than: $16,764 but less than or equal to $56,273 if single or married filing separately with no dependents; $22,704 but less than or equal to

$89,032 if married filing jointly with no dependents or head of household/married filing separately with one dependent; or $28,644 but less than or equal to

$119,270 if married filing jointly with one or more dependents or head of household/married filing separately with two or more dependents, go to line 2.

2. Enter the monthly premium that corresponds with your income range (from line 1 of worksheet) and filing status from

Table 3: Affordability on page HC-8. To find this amount, look at the row for your income range in col. a of the appro-

priate table based on your filing status and go to col. b to find the monthly premium amount . . . . . . . . . . . . . . . . . . . . . . . . . 2

3. Enter the lowest monthly premium cost of health insurance that would cover you, and your spouse and dependent

children, if any, offered to you during your uninsured period in 2012 through an employer. The employer’s Human

Resources Department should be able to provide this amount to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Note: If you declined employer-sponsored health insurance that met Minimum Creditable Coverage, the monthly premium amount may be found on the

Health Insurance Responsibility Disclosure Form (HIRD) you should have received from your employer.

If line 3 is less than or equal to line 2: you are deemed able to afford employer-sponsored health insurance that met Minimum Creditable Coverage dur-

ing your uninsured period(s), which you did not obtain, and you are subject to a penalty. Fill in the Yes oval(s) in line 10 of Schedule HC, and go to the

Health Care Penalty Worksheet on page HC-9.

If line 3 is greater than line 2: you could not afford health insurance that met Minimum Creditable Coverage offered to you by your employer, fill in the No

oval(s) in line 10 of Schedule HC, and complete the following Schedule HC Worksheet for Line 11 on page HC-7.

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