Fillable Printable Form 1095-A - Health Insurance Marketplace Statement (2015)

Form 1095-A - Health Insurance Marketplace Statement (2015)

Form 1095-A

2015

Department of the Treasury

Internal Revenue Service

Health Insurance Marketplace Statement

▶

Information about Form 1095-A and its separate instructions

is at www.irs.gov/form1095a.

OMB No. 1545-2232

VOID

CORRECTED

Part I

Recipient Information

1 Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer's name

4 Recipient's name

5 Recipient's SSN 6 Recipient's date of birth

7 Recipient's spouse's name 8 Recipient's spouse's SSN 9 Recipient's spouse's date of birth

10 Policy start date 11 Policy termination date 12 Street address (including apartment no.)

13 City or town 14 State or province 15 Country and ZIP or foreign postal code

Part II

Covered Individuals

A. Covered individual name B.

Covered individual SSN

Covered individual

date of birth

Coverage start date

Coverage termination date

Part III

Coverage Information

Month

A. Monthly enrollment premiums B. Monthly second lowest cost silver

plan (SLCSP) premium

C. Monthly advance payment of

premium tax credit

21 January

22 February

23 March

24 April

25 May

26 June

27 July

28 August

29 September

30 October

31 November

32 December

33 Annual Totals

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60703Q

Form 1095-A (2015)

Page 2

Instructions for Recipient

You received this Form 1095-A because you or a family member

enrolled in health insurance coverage through the Health Insurance

Marketplace. This Form 1095-A provides information you need to

complete Form 8962, Premium Tax Credit (PTC). You must

complete Form 8962 and file it with your tax return if any

amount other than zero is shown in Part III, Column C, of this

Form 1095-A (meaning that you received premium assistance

through advance credit payments) or if you want to take the

premium tax credit. The filing requirement applies whether or not

you're otherwise required to file a tax return. The Marketplace has

also reported the information on this form to the IRS. If you or your

family members enrolled at the Marketplace in more than one

qualified health plan policy, you will receive a Form 1095-A for each

policy. Check the information on this form carefully. Please contact

your Marketplace if you have questions concerning its accuracy. If

you or your family members were enrolled in a Marketplace

catastrophic health plan or separate dental policy, you aren't

entitled to take a premium tax credit for this coverage when you file

your return, even if you received a Form 1095-A for this coverage.

For additional information related to Form 1095-A, go to

www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Health-

Insurance-Marketplace-Statements.

VOID box. If the "VOID" box is checked at the top of the form, you

previously received a Form 1095-A for the policy described in Part I.

That Form 1095-A was sent in error. You shouldn't have received a

Form 1095-A for this policy. Don't use the information on this or the

previously received Form 1095-A to figure your premium tax credit

on Form 8962.

CORRECTED box. If the "CORRECTED" box is checked at the top

of the form, use the information on this Form 1095-A to figure the

premium tax credit and reconcile any advance credit payments on

Form 8962. Don't use the information on the original Form 1095-A

you received for this policy.

Part I. Recipient Information, lines 1–15. Part I reports information

about you, the insurance company that issued your policy, and the

Marketplace where you enrolled in the coverage.

Line 1. This line identifies the state where you enrolled in coverage

through the Marketplace.

Line 2. This line is the policy number assigned by the Marketplace

to identify the policy in which you enrolled. If you are completing

Part IV of Form 8962, enter this number on line 30, 31, 32, or 33,

box a.

Line 3. This is the name of the insurance company that issued your

policy.

Line 4. You are the recipient because you are the person the

Marketplace identified at enrollment who is expected to file a tax

return and who, if qualified, would take the premium tax credit for

the year of coverage.

Line 5. This is your social security number. For your protection, this

form may show only the last four digits. However, the Marketplace

has reported your complete social security number to the IRS.

Line 6. A date of birth will be entered if there is no social security

number on line 5.

Lines 7, 8, and 9. Information about your spouse will be entered

only if advance credit payments were made for your coverage. The

date of birth will be entered on line 9 only if line 8 is blank.

Lines 10 and 11. These are the starting and ending dates of the

policy.

Lines 12 through 15. Your address is entered on these lines.

Part II. Covered Individuals, lines 16–20. Part II reports

information about each individual who is covered under your policy.

This information includes the name, social security number, date of

birth, and the starting and ending dates of coverage for each

covered individual. For each line, a date of birth is reported in

column C only if an SSN isn't entered in column B.

If advance credit payments are made, only the individuals for

whom you attested the intention to claim a personal exemption

deduction (yourself, spouse, and dependents) to the Marketplace at

enrollment will be listed on Form 1095-A. If you attested to the

Marketplace at enrollment that one or more of the individuals who

enrolled in the plan aren't individuals for whom you intend to claim a

personal exemption deduction on your tax return, those individuals

won't be listed on your Form 1095-A. For example, if you indicated

to the Marketplace at enrollment that an individual enrolling in the

policy is your adult child for whom you won't claim a personal

exemption deduction, that child will receive a separate Form 1095-A

and won't be listed in Part II on your Form 1095-A.

If advance credit payments weren't made and you didn't identify

at enrollment the individuals for whom you intended to claim a

personal exemption deduction, Form 1095-A will list all enrolled

individuals in Part II on your Form 1095-A.

Part II also tells the IRS the months that the individuals identified

are covered by health insurance and therefore have satisfied the

individual shared responsibility provision.

If there are more than 5 individuals covered by a policy, you will

receive one or more additional Forms 1095-A that continue Part II.

Part III. Coverage Information, lines 21–33. Part III reports

information about your insurance coverage that you will need to

complete Form 8962 to reconcile advance credit payments or to

take the premium tax credit when you file your return.

Column A. This column is the monthly premiums for the plan in

which you or family members were enrolled, including premiums

that you paid and premiums that were paid through advance

payments of the premium tax credit. If you or a family member

enrolled in a separate dental plan with pediatric benefits, this

column includes the portion of the dental plan premiums for the

pediatric benefits. If your plan covered benefits that aren't essential

health benefits, such as adult dental or vision benefits, the amount

in this column will be reduced by the premiums for the non-

essential benefits. If the policy was terminated by your insurance

company due to nonpayment of premiums for one or more months,

then a -0- will appear in this column for these months regardless of

whether advance credit payments were made for these months.

Column B. This column is the monthly premium for the second

lowest cost silver plan (SLCSP) that the Marketplace has

determined applies to members of your family enrolled in the

coverage. The applicable SLCSP premium is used to compute your

monthly advance credit payments and the premium tax credit you

take on your return. See the Instructions for Form 8962, Part II, on

how to use the information in this column or how to complete Form

8962 if there is no information entered. If the policy was terminated

by your insurance company due to nonpayment of premiums for

one or more months, then a -0- will appear in this column for the

months, regardless of whether advance credit payments were made

for these months.

Column C. This column is the monthly amount of advance credit

payments that were made to your insurance company on your

behalf to pay for all or part of the premiums for your coverage. If this

is the only column in Part III that is filled in with an amount other

than zero for a month, it means your policy was terminated by your

insurance company due to nonpayment of premiums, and you

aren't entitled to take the premium tax credit for that month when

you file your tax return. You still must reconcile the entire advance

payment that was paid on your behalf for that month using Form

8962. No information will be entered in this column if no advance

credit payments were made.

Lines 21–33. The Marketplace will report the amounts in columns A,

B, and C on lines 21–32 for each month and enter the totals on line

33. Use this information to complete Form 8962, line 11 or lines

12–23.