Qualified Health Plan Disclaimer for Advance Premium Tax Credit (1).pdf

Qualified Health Plan Disclaimer for Advance Premium Tax Credit

The following disclaimer appears if you enroll in a Qualified Health Plan and select Advance Premium Tax Credit (APTC).

This disclaimer explains your tax filing responsibilities and any potential changes in premiums and APTC. Make sure you understand the details of this disclaimer, there could be significant impact to your financial help or federal income tax filing.

When this disclaimer appears on screen in your actual application, the fields noted as [YYYY] below will display the corresponding tax year for your application.

A screenshot of this disclaimer as it appears in the application is on Page 2. ________________________________________________________________________________

Disclaimer Text:

I understand that because advance payments of the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or dependents:

• I must file a federal income tax return in [YYYY] for the tax year
• If I’m married at the end of [YYYY], I must file a joint income tax return with my spouse.

I also expect that:

• No one else will be able to claim me as a dependent on their [YYYY] federal income tax return.
• I’ll claim a personal exemption deduction on my [YYYY] federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through this Marketplace and whose premium for coverage is paid in whole or in part by advance payments.

If any of the above changes, I understand that it may impact my ability to get an advance premium tax credit. I also understand that when I file my [YYYY] federal tax return, the Internal Revenue Service (IRS) will compare the amount of advance tax credit I used during [YYYY] with the amount of tax credit I am eligible to receive based on my actual annual income. If my actual annual income is higher than what I listed in my application, I may not be eligible for the tax credit I used in [YYYY], and will have to pay some or all of it back to the IRS when I file my federal income tax return. If my actual annual income is lower than what I listed in my application, I may be eligible to get an additional tax credit amount back from the federal government.

Potential Changes in Premiums and APTC amounts applied to the Qualified Health Plan (QHP) premium

The maximum amount of the tax credit you may apply towards the QHP premium depends on the total monthly premium of the selected QHP. Please be aware that your monthly premium may change as members begin or end their coverage. Premiums are determined by the number of household members on the QHP each month. If all household members have the same QHP coverage effective date, the monthly premium may not change. However, if household members’ QHP coverage effective dates differ (e.g., household member is added to the QHP one month after the rest of the household begins coverage), monthly premiums will reflect those changes. The APTC amount you select will be applied to the monthly premiums accordingly, and the APTC amount will not exceed the total monthly premium. If the maximum APTC value changes throughout the year, this may impact the amount of tax credit you are able to receive at the end of the year, and in some cases may require you to make additional payments.

Please contact Access Health CT for additional details.