1 CAUTION: NOT FOR FILING Form 1095-A is provided here for informational purposes only. Health Insurance Marketplaces use Form 1095-A to report information on enrollments in a qualified health plan in the individual market through the Marketplace. As the form is to be completed by the Marketplaces, individuals cannot complete and use Form 1095-A available on IRS.gov. Individuals receiving a completed Form 1095-A from the Health Insurance Marketplace will use the information received on the form and the guidance in the instructions to assist them in filing an accurate tax return.
2 OMB No. 1545-2232 VOID Health Insurance Marketplace Statement Form 1095-A ▶ Do not attach to your tax return. Keep for your records. CORRECTED Department of the Treasury 20 18 ▶ Internal Revenue Service Go to for instructions and the latest information. www.irs.gov/Form1095A Recipient Information Part I Marketplace identifier 2 Marketplace-assigned policy number 3 Policy issuer’s name 1 Recipient’s name 5 Recipient’s SSN 6 Recipient’s date of birth 4 Recipient’s spouse’s name 7 9 Recipient’s spouse’s date of birth 8 Recipient’s spouse’s SSN Policy start date Policy termination date 12 Street address (including apartment no.) 10 11 City or town 14 State or province 15 Country and ZIP or foreign postal code 13 Covered Individuals Part II C. Covered individual Covered individual SSN A. Covered individual name B. Coverage termination date D. Coverage start date E. date of birth 16 17 18 19 20 Coverage Information Part III A. Monthly enrollment premiums B. Monthly second lowest cost silver Monthly advance payment of C. Month premium tax credit plan (SLCSP) premium 21 January 22 February 23 March 24 April 25 May June 26 27 July 28 August 29 September 30 October 31 November 32 December 33 Annual Totals Form 1095-A (2018) For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No. 60703Q
3 Form 1095-A (2018) Page 2 If advance credit payments are made, the only individuals listed on Instructions for Recipient Form 1095-A will be those whom you certified to the Marketplace would be in your tax family for the year of coverage (yourself, spouse, and You received this Form 1095-A because you or a family member dependents). If you certified to the Marketplace at enrollment that one or enrolled in health insurance coverage through the Health Insurance more of the individuals who enrolled in the plan aren’t individuals who Marketplace. This Form 1095-A provides information you need to would be in your tax family for the year of coverage, those individuals You must complete complete Form 8962, Premium Tax Credit (PTC). won’t be listed on your Form 1095-A. For example, if you indicated to Form 8962 and file it with your tax return (Form 1040 or Form the Marketplace at enrollment that an individual enrolling in the policy is 1040NR) if any amount other than zero is shown in Part III, column your adult child who will not be your dependent for the year of coverage, C, of this Form 1095-A (meaning that you received premium that child will receive a separate Form 1095-A and won’t be listed in assistance through advance credit payments) or if you want to take Part II on your Form 1095-A. The filing requirement applies whether or not the premium tax credit. you’re otherwise required to file a tax return. If you are filing Form 8962, If advance credit payments are made and you certify that one or more you cannot file Form 1040NR-EZ, Form 1040-SS, or Form 1040-PR. The enrolled individuals aren’t individuals who would be in your tax family for Marketplace also has reported the information on this form to the IRS. If the year of coverage, your Form 1095-A will include coverage you or your family members enrolled at the Marketplace in more than information in Part III that is applicable solely to the individuals listed on one qualified health plan policy, you will receive a Form 1095-A for each your Form 1095-A, and separately issued Forms 1095-A will include policy. Check the information on this form carefully. Please contact your coverage information, including dollar amounts, applicable to those Marketplace if you have questions concerning its accuracy. If you or individuals not in your tax family. your family members were enrolled in a Marketplace catastrophic health If advance credit payments weren’t made and you didn’t identify at plan or separate dental policy, you aren’t entitled to take a premium tax enrollment the individuals who would be in your tax family for the year of credit for this coverage when you file your return, even if you received a coverage, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A for this coverage. For additional information related to Form 1095-A. Form 1095-A, go to Part II also tells the IRS the months that the individuals identified are www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Health- covered by health insurance and therefore have satisfied the individual Insurance-Marketplace-Statements . shared responsibility provision. For additional information about the tax Additional information. If there are more than 5 individuals covered by a policy, you will provisions of the Affordable Care Act (ACA), including the individual receive one or more additional Forms 1095-A that continue Part II. shared responsibility provisions, the premium tax credit, and the www.irs.gov/Affordable- employer shared responsibility provisions, see Part III. Coverage Information, lines 21–33. Part III reports information or call the IRS Healthcare Hotline for Care-Act/Individuals-and-Families about your insurance coverage that you will need to complete Form ACA questions (1-800-919-0452). 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return. If the “VOID” box is checked at the top of the form, you VOID box. previously received a Form 1095-A for the policy described in Part I. Column A. This column is the monthly premiums for the plan in which That Form 1095-A was sent in error. You shouldn’t have received a you or family members were enrolled, including premiums that you paid Form 1095-A for this policy. Don’t use the information on this or the and premiums that were paid through advance payments of the previously received Form 1095-A to figure your premium tax credit on premium tax credit. If you or a family member enrolled in a separate Form 8962. dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered If the “CORRECTED” box is checked at the top of CORRECTED box. benefits that aren’t essential health benefits, such as adult dental or the form, use the information on this Form 1095-A to figure the premium vision benefits, the amount in this column will be reduced by the tax credit and reconcile any advance credit payments on Form 8962. premiums for the non-essential benefits. If the policy was terminated by Don’t use the information on the original Form 1095-A you received for your insurance company due to nonpayment of premiums for one or this policy. more months, then a -0- will appear in this column for these months Part I reports information Part I. Recipient Information, lines 1–15. regardless of whether advance credit payments were made for these about you, the insurance company that issued your policy, and the months. Marketplace where you enrolled in the coverage. This column is the monthly premium for the second lowest Column B. This line identifies the state where you enrolled in coverage Line 1. cost silver plan (SLCSP) that the Marketplace has determined applies to through the Marketplace. members of your family enrolled in the coverage. The applicable SLCSP Line 2. This line is the policy number assigned by the Marketplace to premium is used to compute your monthly advance credit payments identify the policy in which you enrolled. If you are completing Part IV of and the premium tax credit you take on your return. See the instructions Form 8962, enter this number on line 30, 31, 32, or 33, box a. 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 This is the name of the insurance company that issued your Line 3. policy was terminated by your insurance company due to nonpayment policy . of premiums for one or more months, then a -0- will appear in this Line 4. You are the recipient because you are the person the column for the months, regardless of whether advance credit payments Marketplace identified at enrollment who is expected to file a tax return were made for these months. and who, if qualified, would take the premium tax credit for the year of This column is the monthly amount of advance credit Column C. coverage. payments that were made to your insurance company on your behalf to Line 5. This is your social security number. For your protection, this pay for all or part of the premiums for your coverage. If this is the only form may show only the last four digits. However, the Marketplace has column in Part III that is filled in with an amount other than zero for a reported your complete social security number to the IRS. month, it means your policy was terminated by your insurance company Line 6. A date of birth will be entered if there is no social security due to nonpayment of premiums, and you aren’t entitled to take the number on line 5. 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 Information about your spouse will be entered only if Lines 7, 8, and 9. for that month using Form 8962. No information will be entered in this advance credit payments were made for your coverage. The date of column if no advance credit payments were made. birth will be entered on line 9 only if line 8 is blank. The Marketplace will report the amounts in columns A, B, Lines 21–33. These are the starting and ending dates of the policy. Lines 10 and 11. –32 for each month and enter the totals on line 33. Use and C on lines 21 Lines 12 through 15. Your address is entered on these lines. this information to complete Form 8962, line 11 or lines 12–23. Part II reports information Part II. Covered Individuals, lines 16–20. 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.