Fillable Form 13599 - Rating In State-Qualified Private Plans printable pdf download

13599

Form

OMB Clearance No. 1545-1888

July 2004

Rating in State-Qualified Private Plans

The Trade Act of 2002, Public Law No. 107-21 0 created the Health Coverage Tax Credit (HCTC) for the purchase of health

coverage by certain individuals. Eligibility for the HCTC is determined on a monthly basis. For each month an individual claims the

credit, whether in advance or on their federal tax return, he or she must meet certain requirements including enrollment in a qualified

health plan. Only specific health plans qualify for the HCTC. A qualified health plan is one that is allowable under the HCTC

legislation including three automatically qualified plan types or a state-qualified health plan. A state-qualified health plan is one that a

State elects as qualified specifically for the HCTC program and must meet the legislative requirements for health insurance set forth

in the Trade Act of 2002 and codified in Internal Revenue Code Section 35(e)(2).

This form should be completed by a representative of the state for the health care option you recently submitted to the HCTC

program for review. Please complete this form according to the type of product your state has submitted for HCTC. The product types

are outlined in item 1. If you have any questions while filling out this form, please contact Steve Finan at the Department of the US

Treasury at (202) 622-1446. Thank you in advance for your participation. Once completed, please send the form back to us by fax

or mail.

Fax Number:

Mailing Address:

1-800-675-9602

ATTN: HCTC State-Qualified

Accenture 15115 Park Row

Houston, TX 77084

Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your response is voluntary. You

are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number.

Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law.

Generally, tax returns and return information are confidential, as required by code section 6103. The estimated average time to complete this form is 30 minutes. If you

have comments concerning the accuracy of this time estimate or suggestions for making this form simpler, we will be happy to hear from you. You can write to the Tax

Products Coordinating Committee, Western Area Distribution Center, Rancho Cordova, CA 95743-0001. Do NOT send this form to this address. Instead, enclose it with

the magnetic tape and send it to the Service Center to which you submit your tapes or send it to the transmission reception site that received your transmitted returns.

State:

Date:

Contact Name:

Phone:

Title:

Email:

Organization:

Is this product offered to HCTC eligibles through: (CHECK ONE)

a. An Individual Plan (Please answer questions in Section 2)

b. A Group Plan (Please answer questions in Section 3)

c. Another Pooling Arrangement (Please answer question in Section 4)

If it is an INDIVIDUAL plan: complete questions 2A through 2E.