Learn about health care reform for individuals

Find out what Massachusetts health care reform means to you as an individual.

The Massachusetts Health Care Reform Law requires that most residents over 18 who can afford health insurance have coverage for the entire year, or pay a penalty through their tax returns. Penalties add up for each month you don't comply, but there is a grace period that allows lapses in coverage of 3 or fewer consecutive months. You must be enrolled in health insurance plans that meet Minimum Creditable Coverage (MCC) requirements.

Most adults already have health insurance, perhaps through their employer or a government program, but if you don't, you or your employer can find the right health insurance plan online.

You may also buy plans through approved Massachusetts health insurance carriers. To learn more or buy a plan, contact the Health Connector at (877) 623-6765, TTY number at (877) 623-7773, or visit the website.

Requirements

Whether you file or have to file a Massachusetts personal income tax return, anyone 18 years old or over must get and maintain creditable health insurance coverage as long as it's considered affordable under the schedule set by the Massachusetts Health Connector. This includes those who are exempt from filing taxes. This health care mandate applies to:

  • Massachusetts residents, and
  • People who become Massachusetts residents within 63 days. Residents who terminate any prior creditable coverage within 63 days must get and maintain creditable coverage within 63 days of terminating.

If you're a resident, or in some cases a part-year resident, file Schedule HC with your Form 1 or Form 1-NR/PY. If you don't, this will delay processing your return. Fill in the Health Care Information section on your Schedule HC to prove that you have health insurance that meets MCC requirements. (Note that when Schedule HC instructions for line 11 ask if "you applied for MassHealth or Commonwealth Care and were denied", "denied" means that you were denied because you weren't eligible for those government-subsidized insurances, not denied for administrative reasons such as failing to return the forms necessary for determining eligibility.)

If you have health insurance from more than 2 insurance carriers, fill out Schedule HC-CS as well. Report your 2 most recent insurance carriers first on Schedule HC first and then fill out Schedule HC-CS to report your additional insurance carriers.

If you turned 18 in the past tax year, the health care mandate applies to you beginning on the first day of the third full month following your birthday.

If a taxpayer dies during the year, the health care mandate applies to the deceased up until the last day of the last full month that they were alive.

Your health care premiums are tax-deductible if you're self-employed, so you can reduce your taxable income by your health insurance premium's cost. This is reported on Schedule Y of your Massachusetts income tax return. The Massachusetts Health Connector offers health plans on a pre-tax basis.

Children and/or dependents

If you have an insured benefit plan that provides coverage for dependents, your child can stay on your health plan through the earlier of:

  • Their 26th birthday
  • 2 years after they lost their dependent status according to federal tax rules

If your plan is a self-insured plan, check with your plan sponsor to find out how long dependents can stay on your plan. See here for more information on the personal income tax treatment of this benefit.

Carriers can't impose any limitations on eligibility for dependent coverage, other than limitations defining familial relationships under the policy (e.g., spouse and children, or spouse, children and parents) and any other limitations that may be allowed.

Changes in residency

If you moved into Massachusetts during the year, the health care mandate applies to you beginning on the first day of the third full month following the month you became a Massachusetts resident.

If you moved out of Massachusetts during the year, the health care mandate applies to you up until the last day of the last full month you were a resident.

If you're a retired Massachusetts resident now living abroad, and you have full health insurance in the country you live in, you can complete your Schedule HC by either:

If you were living out of the state (a nonresident of Massachusetts), and thus filed your income tax return in the state you lived in before, you aren't subject to the mandate. However, to avoid penalties in the future, you should contact the Massachusetts Health Connector at (877) 623-6765, TTY number at (877) 623-7773, or visit them online.

Additional Resources

Minimum Creditable Coverage (MCC)

Minimum Creditable Coverage (MCC) is the minimum level of benefits that you need to be considered insured and avoid tax penalties in Massachusetts. These benefits include:

  • Coverage for a comprehensive set of services (e.g. doctors visits, hospital admissions, day surgery, emergency services, mental health and substance abuse, and prescription drug coverage).
  • Doctor visits for preventive care, without a deductible.
  • A cap on annual deductibles of $2,000 for an individual and $4,000 for a family.
  • For plans with up-front deductibles or co-insurance on core services, an annual maximum on out-of-pocket spending of no more than the annual limit set by the IRS for high deductible health plans. In 2014, out-of-pocket costs are limited to $6,350 for an individual plan and $12,700 for a family plan.
  • No caps on total benefits for a particular illness or for a single year.
  • No policy that covers only a fixed dollar amount per day or stay in the hospital, with the patient responsible for all other charges.
  • For policies that have a separate prescription drug deductible, it cannot exceed $250 for an individual or $500 for a family.

If your plan doesn't meet the MCC requirements for the entire time that the mandate applied to you, fill in the "No MCC/None" oval in line 3 of the Schedule HC. You won't be penalized if we determine that you didn't have access to affordable insurance that met MCC.

Plans that meet MCC

Most plans meet the MCC standards. You'll know if your plan does because Massachusetts-licensed health insurance companies must put an MCC-compliance notice on their plans to indicate if it does or doesn't meet MCC.

If you receive a Form MA 1099-HC from your insurer, it will indicate whether your insurance meets MCC requirements. If you didn't receive one from your insurer and get health coverage through your job, you can call your insurer or your employer's human resources department or benefits administrator for help. If your insurer or your employer can't help you, please refer to list of benefits above to see if your policy meets these requirements. If your plan meets all of the requirements listed above, you may certify that you were enrolled in a plan that met the MCC requirements during that time period.

You automatically meet MCC if you're enrolled in:

  • Medicare Part A or B
  • Any Qualified Health Plan purchased through the Massachusetts Health Connector or directly through an insurance carrier, including catastrophic plans
  • MassHealth
  • A federally-qualified high deductible health plan (HDHP)
  • A Student Health Insurance Plan (SHIP) offered in Massachusetts or another state
  • A tribal or Indian Health Service plan
  • TRICARE
  • The U.S. Veterans Administration Health System
  • A health insurance plan offered by the federal government to federal employees or retirees; or
  • Peace Corps, VISTA or AmeriCorps or National Civilian Community Corps coverage

For years before 2014, you automatically meet MCC if you were enrolled in:

  • Any Commonwealth Care, Commonwealth Care Bridge plan
  • Any Commonwealth Choice plan (including Young Adult Plans)
  • Any of the plans listed above that qualify as MCC in 2014 and beyond

Receiving services through the Health Safety Net Trust Fund (previously known as the "Uncompensated Care Pool" or "Free Care Pool") is not considered health insurance, and thus does not meet MCC requirements. If this is the only way in which your health care needs are paid, you must select the No MCC/None oval in line 3 of the Schedule HC.

If you were enrolled in an MCC plan for only part of a year, you should fill in the "Part-Year MCC" oval in line 3 of the Schedule HC. Next, provide your health insurance information for the MCC plan(s) you were enrolled in. Do not provide health insurance information for a plan that does not meet the MCC standards.

Minimum Creditable Coverage (MCC) and the federal Minimum Essential Coverage (MEC)

Massachusetts is keeping its individual mandate along with the federal mandate from the Affordable Care Act (ACA) while making sure that they work together in a way so no one is subject to "double penalties". Massachusetts will continue to apply the mandate only to adults, even though the federal mandate applies to children.

In some cases, coverage automatically meets MCC. MCC also outlines categories of benefits that must be covered by plans that don't automatically meet MCC, such as employer-sponsored plans or plans in the individual market. For example, a plan must cover doctor visits and prescription drugs to meet MCC.

You must have Minimum Essential Coverage (MEC) to satisfy the federal mandate. Instead of including specific types of benefits, it's generally defined as different types of coverage. These coverage categories include:

  • Plans provided by the government (e.g., Medicare, Medicaid, CHIP, Tricare, etc.)
  • Any plan provided by an employer
  • Any plan purchased in the individual/non-group market (i.e., directly by an individual from an insurance company or Marketplace)
  • Any plan considered a “grandfathered” plan
  • Other plans that apply to the federal government for recognition as MEC and are certified as such.

In almost all cases, plans that meet the state’s MCC requirements also meet the federal MEC requirements. You likely won't experience any changes while filing your taxes or be penalized.

If you don't have MCC compliant coverage, you'll pay whichever penalty is larger. If the federal penalty is greater than the state penalty, you'll pay the full federal penalty but won't pay anything to the state. If the federal penalty is less than the state penalty, you'll pay the full federal penalty to the federal government and the difference between the 2 penalties to the state.

Form MA 1099-HC

This form contains information you need to complete your Schedule HC. Students who are dependents on a parent's insurance plan also need the information on the Form MA 1099-HC to complete their income tax returns.

Insurance carriers (including MassHealth, Commonwealth Care, or Commonwealth Care Bridge) and certain employers are legally required to issue Forms MA 1099-HC no later than January 31 of the following year.

Receiving the form

You will receive a Form MA 1099-HC if:

  • You have private insurance. You (the plan subscriber) will receive a Form MA 1099-HC from your insurance carrier. It'll also list spouse and dependent information. If you didn't get a form, fill in the Health Care Information section of your Schedule HC with the name of your insurance carrier or administrator and your subscriber number. This information should be on your insurance card. If you can't find it, contact your insurer.
  • You're enrolled in MassHealth, Commonwealth Care or Commonwealth Care Bridge and your income is above 150% of the federal poverty level. If you didn't get a Form MA 1099-HC and your income was at or above 150% of the federal poverty level, you can call MassHealth at (800) 841-2900 or the Massachusetts Health Connector at (877) 623-6765 for a copy.

If you receive more than 1 Form MA 1099-HC because you have more than 1 health insurance carrier for the year, you (and/or your spouse, if married filing jointly) must report each carrier that provided health insurance.

If you switched coverage or had more than 1 insurance carrier in the year, you'll receive a Form MA 1099-HC from each carrier showing detailed information about specific months of coverage. You need to report each instance of coverage you had as you complete Schedule HC.

Don't worry if you receive a Form MA 1099-HC that lists your middle initial incorrectly. There will be no problem, since you don't transcribe your name from the Form MA 1099-HC onto the Schedule HC. The important data is the information you carry over from the Form MA 1099-HC to the Schedule HC.

You won't receive a Form 1099-HC if:

  • You're enrolled in:
    • Medicare
    • The Veterans Administration Program
    • Tri-Care
    • Or other government insurance. 
      Instead, you simply fill in the oval for the plan you were enrolled in on line 4 of Schedule HC.
  • Your income is below 150% of the federal poverty level. There is no penalty for people with incomes at or below 150% of the federal poverty level, so you wouldn't need a Form MA-1099-HC. You don't have to answer detailed questions about your coverage on Schedule HC, but you still need to complete it.
  • You have Medicare supplemental insurance or a replacement plan you bought on your own. Medicare includes supplemental and replacement plans for this purpose. However, you should still fill in the Medicare bubble in Schedule HC to complete the form properly.

Additional Resources

Penalty

You'll only be penalized for lacking insurance if you can afford to get health insurance but didn't. The penalties vary depending upon your income, age and family size. Penalties can be no more than half the lowest priced plan available to an individual through the ConnectorCare health insurance.

The individual mandate penalty applies only to adults who can afford health insurance. If, according to the state affordability schedule, you have no affordable options, you won't be penalized. There's no penalty if your income is at or below 150% of the federal poverty level because there is no premium and therefore no penalty. See the guidelines regarding the tax penalties for not having health insurance.

Paying the penalty

Your penalty amount will be calculated and entered on Form 1 or Form 1-NR/PY. If you owe more than you are getting back in refund, pay the amount of tax due on the tax return. We will send a bill if the amount of tax due is not paid with the return.

Appealing the penalty

You can appeal the penalty if you were unable to get affordable insurance due to a hardship or other circumstances. If the Connector denies or dismisses your appeal, you'll receive a bill from DOR.

You can also base your appeal on other circumstances. For example, income changes or life circumstances might have affected your financial status during the year so that applying the affordability tables in Schedule HC was inequitable. You could have been unable to get government-subsidized insurance despite your income, or other circumstances that made you unable to buy insurance.

Hardships

To appeal a penalty, you have to show that you experienced any of the following hardships during the tax year:

  • You were homeless, more than 30 days late in rent or mortgage payments, or received an eviction or foreclosure notice.
  • You received a shut-off notice, were shut off, or were refused the delivery of essential utilities (gas, electric, oil, water, or telephone).
  • Your essential expenses increased significantly and unexpectedly due to the direct consequences of:
    • Domestic violence
    • The death of a spouse, family member, or partner with primary responsibility for child care, where that spouse, family member, or partner shared household expenses with you
    • The sudden responsibility for providing full care for yourself, an aging parent or other family member, including a major, extended illness of a child that required a working parent to hire a full-time caretaker for the child, or
    • A fire, flood, natural disaster, or other unexpected natural or human-caused event causing substantial household or personal damage for the individual filing the appeal.
  • Your financial circumstances were such that the expense of buying health insurance would have caused you to experience a serious deprivation of food, shelter, clothing or other necessities.
  • Your family size was so large that relying on the affordability schedule (see Table 3: Affordability in Schedule HC) to determine how much you could afford to pay for health insurance is inequitable.
  • During the year, you bought health insurance that didn't meet MCC requirements because that is all that your employer offered, and you felt that your circumstances prevented you from buying other insurance that met the requirements.

Additional Resources

Coverage changes

There is a grace period for people who have a gap in coverage. You can go up to 3 consecutive months without penalty, and multiple lapses are allowed within 1 calendar year. Therefore, if you lose your coverage but then resume coverage within 3 or fewer calendar months, you won't be penalized. We'll know how long you've had coverage because insurance carriers submit the same Form MA 1099-HC information to us as well.

If you go 4 or more consecutive months without insurance, you need to determine if you have access to affordable health insurance, either through an employer, the government, or on your own.

Getting insurance in the middle of a month

If you had insurance for 15 days or more in a month, it will be treated as a full month of coverage. Otherwise, coverage of 14 days or less will be counted as a month without coverage. This calculation will be reflected in the Form MA 1099-HC.

Employment

If you can't afford health insurance payments while you're unemployed (before your new health insurance becomes effective through your new employer), check with your previous employer's human resource department about possibly extending your coverage until your new insurance becomes effective. You may also want to speak to the Commonwealth Health Insurance Connector Authority or the Division of Unemployment Assistance about other options. However, if your waiting period is 3 or fewer consecutive months, you fall within the permitted grace period and won't be penalized.

If you recently lost your job but got coverage through COBRA, you won't be subject to penalties. Losing your job is considered a "qualifying event" in most cases, which means that you are temporarily entitled to the same health plan coverage you had while you were employed. As long as the insurance you had through your former employment met MCC standards, you won't be penalized as long as you maintain that coverage through COBRA.

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