Instructions For Schedule Hc - Health Care - 2012 (Page 7 of 10) in pdf

Schedule HC Worksheet for Line 11: Eligibility for Government-

Table 2: Income at 300% of the

Subsidized Health Insurance

Federal Poverty Level

The following worksheet will determine if you were eligible for government-subsidized health insurance

in 2012. Complete the following worksheet only if an employer did not offer you affordable health in-

Family size*

Income

surance that met Minimum Creditable Coverage requirements, as determined in the Schedule HC

Worksheet for Line 10.

$033,516

Note: If you answered Yes in line 6 of Schedule HC indicating that your income was at or below 150%

$045,396

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

$057,276

worksheet. Skip the remainder of Schedule HC and continue completing your return.

If married filing separately and living in the same household, each spouse must combine their income

$069,156

figures from their separate U.S. returns when completing this worksheet. Also, same-sex spouses filing

$081,036

a Massachusetts joint return or married filing separately and living in the same household must com-

bine their income figures from their separate U.S. returns when completing this worksheet.

$092,916

1. Enter your income before adjustments (from U.S. Form 1040,

line 22, Form 1040A, line 15 or Form 1040EZ, line 4) . . . . . . . . . . . . 1

$104,796

2. Enter the amount from the Income column, based on your family

$116,676

size (do not include dependent children age 19 or older in your

family size), from Table 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

$128,556

If line 1 is greater than line 2: you were ineligible for government-subsidized health insurance in 2012

$140,436

and must fill in the No oval(s) in line 11 of Schedule HC, and go to Schedule HC Worksheet for Line 12

to determine if you were deemed able to afford private health insurance.

$152,316

If line 1 is less than or equal to line 2, and at any point during the period when you were unin-

$164,196

sured: you were not a citizen or an alien legally residing in the U.S., or an employer offered to pay

more than 20% of a family plan or 33% of an individual plan (the employer’s Human Resources De-

$176,076

partment should be able to provide this information to you), or you applied for MassHealth or Common-

wealth Care and were denied because you were ineligible for services, you are deemed ineligible for

*Include only yourself, your spouse (if married

government-subsidized health insurance in 2012. Fill in the No oval(s) in line 11 of Schedule HC,

filing a joint return) and any dependent children

and go to Schedule HC Worksheet for Line 12 to determine if you were able to afford private health in-

age 18 or younger in your family size. For fam-

surance. Note: Prior to May 1, 2012, most legal permanent residents who lived in the United States for

ily size over 13, add $11,880 for each additional

fewer than five years were not eligible for coverage through the Commonwealth Care program. If you

family member.

were an Alien With Special Status (AWSS) and uninsured before May, fill in the No oval(s) in line 11 of

Schedule HC, and go to Schedule HC Worksheet for Line 12 to determine if you were able to afford

private health insurance.

If line 1 is less than or equal to line 2, and none of the above conditions apply, you would have been deemed eligible for government-subsidized

health insurance in 2012, which you did not obtain and you are subject to a penalty. Fill in the Yes oval(s) in line 11 of Schedule HC and go to the Health

Care Penalty Worksheet on page HC-9. Note: If you believe that, during the period when you were uninsured, your income was actually too high to qualify

for government-subsidized insurance, you may have grounds to appeal the penalty. Fill in the Yes oval(s) in line 11 of Schedule HC and go to the instruc-

tions for the Appeals section.

Schedule HC Worksheet for Line 12: Ability to Purchase Affordable Private Health Insurance That

Met Minimum Creditable Coverage

The following worksheet will determine if you could have purchased affordable private health insurance that met Minimum Creditable Coverage in 2012.

Complete the following worksheet only if you (and/or your spouse if married filing jointly) were deemed ineligible for government-subsidized health insur-

ance, as determined in the Schedule HC Worksheet for line 11.

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 in line 7 of Schedule HC, the penalty does not apply to you. Do not complete this

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

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

2. Enter the monthly premium that corresponds with your county of residency, age (if married filing a joint return, use the

age of the older spouse) and filing status from Table 4: Premiums on page HC-8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Go to the table that corresponds to your county of residency and go to the row for your age range and then go to the column based on your filing status to

find the monthly premium amount.

3. 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 . . . . . . . . . . . . . . . . . . . . . . . . . 3

If line 2 is greater than line 3: you are deemed unable to afford health insurance that met Minimum Creditable Coverage and not subject to a penalty, and

you must fill in the No oval(s) in line 12 of Schedule HC and skip the remainder of Schedule HC and continue completing your tax return.

If line 2 is less than or equal to line 3, and at any point during the period when you were uninsured: you were 27 years or older and were offered in-

surance that met Minimum Creditable Coverage through an employer, or you were 18–26 years old and were offered insurance from an employer towards

which the employer paid 33% or more of the total premium (the employer’s Human Resources Department should be able to provide this information to

you), you are deemed ineligible to purchase private health insurance in 2012. Fill in the No oval(s) in line 12 of Schedule HC and skip the remainder of

Schedule HC and continue completing your tax return. Be sure to enclose Schedule HC with your tax return.

If line 2 is less than or equal to line 3 and none of the above conditions apply: you are deemed able to afford private health insurance that met Mini-

mum Creditable Coverage, which you did not obtain; you are subject to a penalty and you must fill in the Yes oval(s) in line 12 of Schedule HC and go to the

Health Care Penalty Worksheet on page HC-9.

HC-7

Instructions For Schedule Hc - Health Care - 2012 Page 7

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