Instructions for Form 1095-A (2017)

Health Insurance Marketplace Statement

Section references are to the Internal Revenue Code unless otherwise noted.

2017


Instructions for Form 1095-A - Main Contents

Future Developments

For the latest information about developments related to Form 1095-A and its instructions, such as legislation enacted after they were published, go to IRS.gov/Form1095A.

Additional Information

For information related to the Affordable Care Act, visit IRS.gov/Affordable-Care-Act.

For additional information related to Form 1095-A, visit IRS.gov/Affordable-Care-Act/Individuals-And-Families/Health-Insurance-Marketplace-Statements.

General Instructions

Purpose of Form

Form 1095-A is used to report certain information to the IRS about individuals who enroll in a qualified health plan through the Health Insurance Marketplace. Form 1095-A also is furnished to individuals to allow them to take the premium tax credit, to reconcile the credit on their returns with advance payments of the premium tax credit (advance credit payments), and to file an accurate tax return.

Who Must File

Health Insurance Marketplaces must file Form 1095-A to report information on all enrollments in qualified health plans in the individual market through the Marketplace. Do not file a Form 1095-A for a catastrophic health plan or a separate dental policy (called a "stand-alone dental plan" in these instructions).

When To File

File the annual report with the IRS and furnish the statements to individuals on or before January 31, 2018, for coverage in calendar year 2017.

The requirement to furnish a statement to individuals will be met if the Form 1095-A is properly addressed and mailed or furnished electronically (if the recipient has consented to electronic receipt) on or before the due date. If the regular due date falls on a Saturday, Sunday, or legal holiday, furnish the statement by the next business day. A business day is any day that isn't a Saturday, Sunday, or legal holiday.

How To File

Electronic filing.

You must submit the information to the IRS electronically. Submit the information through the Department of Health and Human Services Data Services Hub.

Statements to Individuals

Furnishing required information to the individual.

Marketplaces use Form 1095-A to furnish the required statement to recipients. A separate Form 1095-A must be furnished for each policy and the information on the Form 1095-A should relate only to that policy. If two or more tax filers are enrolled in one policy, each tax filer receives a statement reporting coverage of only the members of that tax filer's tax household. See the instructions for line 4 for more information about who is a recipient. Don't furnish a Form 1095-A for a catastrophic health plan or a stand-alone dental plan. See the instructions for Part III, column A.

On Form 1095-A statements furnished to recipients, filers of Form 1095-A may truncate the social security number (SSN) of an individual receiving coverage by showing only the last four digits of the SSN and replacing the first five digits with asterisks (*) or Xs. Truncation isn't allowed on forms filed with the IRS.

Statements must be furnished to recipients on paper by mail, unless a recipient affirmatively consents to receive the statement in an electronic format. If mailed, the statement must be sent to the recipient’s last known permanent address, or if no permanent address is known, to the recipient’s temporary address.

Consent to furnish statement electronically.

The requirement to obtain affirmative consent to furnish a statement electronically ensures that statements are sent electronically only to individuals who are able to access them. A recipient may provide his or her consent on paper or electronically, such as by e-mail. If consent is provided on paper, the recipient must confirm the consent electronically. An electronic statement may be furnished by e-mail or by informing the recipient how to access the statement on a Marketplace’s website (for example, in the recipient's Marketplace account).

Specific Instructions

Part I—Recipient Information

Line 1.

Enter the Marketplace state name or abbreviation.

Line 2.

Enter the number the Marketplace assigned to the policy. If the policy number is greater than 15 characters, enter only the last 15 characters.

Line 3.

Enter the name of the issuer of the policy.

Line 4.

Enter the name of the recipient of the statement. This should be the person identified at enrollment as the tax filer (the person who is expected to file a tax return, to claim other family members as dependents, and who, if qualified, would take the premium tax credit for the year of coverage for his or her household). If the tax filer can't be identified from the information provided at enrollment (for example, because no financial assistance was requested), enter the name of the primary applicant for the coverage.

Line 5.

Enter the social security number (SSN) for the recipient shown on line 4.

Line 6.

Enter the recipient’s date of birth only if line 5 is blank.

Lines 7, 8, and 9.

Enter information about the recipient’s spouse, if any, if advance credit payments were made for the coverage. Enter this information even if the advance credit payments weren't made for the spouse's coverage. Enter a date of birth only if line 8 is blank.

Line 10.

Enter the date that coverage under the policy started. If the policy was in effect at the start of the year, enter 1/1/2017.

Line 11.

Enter the date of termination if the policy was terminated during the year. If the policy was in effect at the end of the year, enter 12/31/2017.

Lines 12–15.

Enter the recipient's address.

Part II—Covered Individuals

Enter on lines 16 through 20 and columns A through E information for each individual covered under the policy, including the recipient and the recipient's spouse, if covered. If advance credit payments weren't made for any coverage under the policy and a tax household can't be identified, enter in Part II information for all covered individuals. If advance credit payments were made for the coverage or a tax household can be identified, enter in Part II information only for covered individuals who are members of the tax filer’s tax household (individuals for whom the tax filer attested to the Marketplace at enrollment the intention to claim a personal exemption deduction on the tax return), that is the tax filer, spouse, and dependents. Information about individuals enrolled in the same policy as the tax filer’s tax household who aren't members of that tax household, including children, must be reported on a separate Form 1095-A.

For each line, enter a date of birth in column C only if column B is blank. Enter in column D the date the coverage started for the individual. Enter in column E the date of termination if the individual's coverage was terminated during the year. If the coverage was in effect at the end of the year, enter 12/31/2017.

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If there are more than 5 covered individuals, complete one or more additional Forms 1095-A, Part II.

Part III—Coverage Information

Enter information in Part III, lines 21 through 32, for each month of coverage. This information is determined on a monthly basis and may change during the year if there is a change in enrollment or other circumstances that affect eligibility for or the amount of the premium tax credit. Total the amounts on lines 21 through 32 and enter on line 33.

Column A.

Enter the total monthly enrollment premiums for the policy in which the covered individuals enrolled. Include only the premiums allocable to essential health benefits. If a covered individual is enrolled in a stand-alone dental plan, include the portion of the premiums for the stand-alone dental plan that is allocable to pediatric dental coverage in the total monthly enrollment premiums. If more than one Form 1095-A is filed for coverage of the recipient’s family for the same months, because, for example, a family member enrolled in a separate policy, include the portion of the premium for pediatric dental coverage in the amount in column A on only one Form 1095-A. If more than one tax filer is enrolled in a policy, report on each tax filer's Form 1095-A only those enrollment premiums allocated to that tax filer. If a policy is terminated by an issuer for nonpayment of premiums, enter -0- for a month in which the covered individuals have coverage but the premiums aren't fully paid (generally, the first month of a grace period). If one or more covered individuals terminate coverage before the last day of a month, the amount reported in this column should not include any amount of the monthly enrollment premium that was refunded.

Column B.

Enter the premiums for the applicable second lowest cost silver plan (SLCSP) that was used as a benchmark to compute monthly advance credit payments. If advance credit payments were made, the applicable SLCSP for a month is the SLCSP that applies to individuals in Part II who were identified at enrollment as members of the tax filer’s family (the individuals who would be claimed as personal exemption deductions on the tax filer’s tax return) and who are enrolled in the coverage on the first day of the month and aren't eligible for other health coverage for that month. However, if an individual enrolls in coverage and the enrollment is effective on the date of the individual's birth, adoption, placement in foster care, or on the effective date of a court order, the individual should be considered to have enrolled on the first day of the month for purposes of the applicable SLCSP premium reported in column B. If all covered individuals enroll after the first of the month, and no individual's coverage is effective on the date of the individual's birth, adoption, placement in foster care, or on the effective date of a court order, enter -0- in column B for that month. If more than one Form 1095-A is filed for coverage of a tax filer’s family for the same month (for example, because members of the family were split among several policies), enter the SLCSP premium that applies to all the family members who were enrolled in any policy on the first of the month and who were not eligible for other health coverage for that month. Enter this SLCSP premium in column B on each Form 1095-A.

In some cases, the information provided at enrollment may not indicate which covered individuals are members of the recipient's family and are not eligible for other health coverage. (Such information may not be provided, for example, because no financial assistance was requested.) If this is the case, and if the Marketplace has provided a tool for determining the applicable SLCSP premium for the year of coverage at the time of filing the tax return, leave column B blank. If the Marketplace has not provided a tool for determining the applicable SLCSP premium, enter the premiums for the SLCSP that would apply to all individuals identified in Part II as covered for the month.

If a policy is terminated by an issuer for nonpayment of premiums and advance credit payments are made, enter -0- for a month in which the covered individuals have coverage but the premiums aren't paid (generally, the first month of a grace period). However, if an individual enrolled on the first day of a month terminates coverage before the last day of the month, the individual should be considered to have been enrolled for the entire month for purposes of the applicable SLCSP premium reported in column B.

Column C.

Enter the amount of advance credit payments for the month. If more than one Form 1095-A is filed for coverage of a tax filer’s family for the same months, enter only the advance credit payment amount allocated to the policy reported on this Form 1095-A. If the tax filer’s family also is enrolled in a stand-alone dental plan, any advance credit payments allocated to the stand-alone dental plan should be added to the advance credit payments allocated to one of the policies reported on a Form 1095-A.

Void Statements

If a Form 1095-A was sent for a policy that shouldn't be reported on a Form 1095-A, such as a stand-alone dental plan or a catastrophic health plan, send a duplicate of that Form 1095-A and check the void box at the top of the form. Provide this information to the IRS and to the recipient of the statement as soon as possible after discovering that the statement was sent in error.

Correction to Information Reported

Report corrected information on the Form 1095-A to the IRS and to the recipient as soon as possible after discovering that information reported is incorrect. Check the corrected box on the top of the form.

Privacy Act and Paperwork Reduction Act Notice.

We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required by the Internal Revenue Code to give us the information. We need it to ensure that taxpayers are complying with these laws and to allow us to figure and collect the right amount of tax.

You aren't required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by IRC section 6103.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Preparing the form .3 min.

 

If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can send us comments from IRS.gov/FormComments. Or you can write to the Internal Revenue Service, Tax Forms and Publications Division, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224. Don't send the form to this office.