Fillable Printable Form 1095-B - Health Coverage (2015)

Form 1095-B - Health Coverage (2015)

Form

1095-B

2015

Department of the Treasury

Internal Revenue Service

Health Coverage

▶

Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b.

OMB No. 1545-2252

560115

VOID

CORRECTED

Part I

Responsible Individual

1 Name of responsible individual 2 Social security number (SSN) 3 Date of birth (If SSN is not available)

4 Street address (including apartment no.) 5 City or town 6 State or province 7 Country and ZIP or foreign postal code

9 Small Business Health Options Program (SHOP) Marketplace identifier, if applicable

Part II

Employer Sponsored Coverage (see instructions)

10 Employer name 11 Employer identification number (EIN)

12 Street address (including room or suite no.) 13 City or town 14 State or province 15 Country and ZIP or foreign postal code

Part III

Issuer or Other Coverage Provider (see instructions)

16 Name 17 Employer identification number (EIN) 18 Contact telephone number

19 Street address (including room or suite no.) 20 City or town 21 State or province 22 Country and ZIP or foreign postal code

Part IV

Covered Individuals (Enter the information for each covered individual(s).)

(a) Name of covered individual(s) (b) SSN (c)

DOB (If SSN is not

available)

(d)

Covered

all 12 months

(e) Months of coverage

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

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

Cat. No. 60704B

Form 1095-B (2015)

Enter letter identifying Origin of the Policy (see instructions for codes): . . . . . .

▶

560215

Form 1095-B (2015)

Page 2

Instructions for Recipient

This Form 1095-B provides information needed to report on your income tax

return that you, your spouse (if you file a joint return), and individuals you

claim as dependents had qualifying health coverage (referred to as “minimum

essential coverage”) for some or all months during the year. Individuals who

don't have minimum essential coverage and don't qualify for an exemption

from this requirement may be liable for the individual shared responsibility

payment.

Minimum essential coverage includes government-sponsored programs,

eligible employer-sponsored plans, individual market plans, and other

coverage the Department of Health and Human Services designates as

minimum essential coverage. For more information on the requirement to

have minimum essential coverage and what is minimum essential coverage,

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

Shared-Responsibility-Provision.

TIP

Providers of minimum essential coverage are required to furnish

only one Form 1095-B for all individuals whose coverage is

reported on that form. As the recipient of this Form 1095-B, you

should provide a copy to other individuals covered under the policy if they

request it for their records.

Part I. Responsible Individual, lines 1–9. Part I reports information about

you and the coverage.

Lines 2 and 3. Line 2 reports your social security number (SSN) or other

taxpayer identification number (TIN), if applicable. For your protection, this

form may show only the last four digits. However, the coverage provider is

required to report your complete SSN or other TIN, if applicable to the IRS.

Your date of birth will be entered on line 3 only if line 2 is blank.

▲

CAUTION

If you don't provide your SSN or other TIN and the SSNs or other TINs

of all covered individuals to the sponsor of the coverage, the IRS may

not be able to match the Form 1095-B with the individuals to

determine that they have complied with the individual shared responsibility

provision.

Line 8. This is the code for the type of coverage in which you or other

covered individuals were enrolled. Only one letter will be entered on this line.

A. Small Business Health Options Program (SHOP)

B. Employer-sponsored coverage

C. Government-sponsored program

D. Individual market insurance

E . Multiemployer plan

F . Other designated minimum essential coverage

TIP

If you or another family member received health insurance

coverage through a Health Insurance Marketplace (also known as

an Exchange), that coverage will be reported on a Form 1095-A

rather than a Form 1095-B.

Line 9. This line will be blank for 2015.

Part II. Employer-Sponsored Coverage, lines 10–15. This part will be

completed by the insurance company if an insurance company provides your

employer-sponsored health coverage. It provides information about the

employer sponsoring the coverage. This part may show only the last four

digits of the employer's EIN. If your coverage isn't insured employer

coverage, this part will be blank.

Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports

information about the coverage provider (insurance company, employer

providing self-insured coverage, government agency sponsoring coverage

under a government program such as Medicaid or Medicare, or other

coverage sponsor). Line 18 reports a telephone number for the coverage

provider that you can call if you have questions about the information

reported on the form.

Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN

or other TIN, and coverage information for each covered individual. A date of

birth will be entered in column (c) only if SSN or other TIN isn't entered in

column (b). Column (d) will be checked if the individual was covered for at

least one day in every month of the year. For individuals who were covered

for some but not all months, information will be entered in column (e)

indicating the months for which these individuals were covered. If there are

more than six covered individuals, see Part IV, Continuation Sheet(s), for

information about the additional covered individuals.

560316

Form 1095-B (2015)

Page 3

Part IV

Covered Individuals — Continuation Sheet

Name of responsible individual Social security number (SSN) Date of birth (If SSN is not available)

(a) Name of covered individual(s) (b) SSN (c)

DOB (If SSN is not

available)

(d)

Covered

all 12 months

(e) Months of coverage

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Form 1095-B (2015)