Massachusetts Health Care Reform Act (for Tax Year 2014)

The following instructions apply for completing this form:

• FEHB coverage is Private Health Insurance (Line 4a) and not other Government Subsidized Health Insurance (Line 4E). Fill in the oval(s) in line 4a and complete Part F (for your) and/or Part G (your spouse) in line 4.
• Massachusetts residents who do not receive a Form 1099 HC from their FEHB plan operating outside of Massachusetts should fill in the plan name and subscriber number (the identification number on your ID card) under Line 4F and 4G, if applicable.
• If a Massachusetts resident fills in his or her FEHB plan name and subscriber number in Line 4F and states in Line 7 the months that he or she was insured for the 2014 year, then the form is complete.

A copy of the 2014 Massachusetts Schedule HC showing the areas that need to be completed by our member is available for your review. For filing instructions and forms, visit http://www.mass.gov/dor/forms/personal-income/2014/form-1.