Form 1095-A- Health Insurance Marketplace Statement

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2014

Instructions for Form 1095-A

Department of the Treasury
Internal Revenue Service

Health Insurance Marketplace Statement
Section references are to the Internal Revenue Code
unless otherwise noted.

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 www.irs.gov/
form1095a.

Additional Information

For information related to the Affordable Care Act, visit
www.irs.gov/ACA.

General Instructions
Purpose of Form

Form 1095-A is used to report certain information to the
IRS about family members who enroll in a qualified health
plan through the Marketplace. Form 1095-A also is
furnished to individuals to allow them to claim 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 through the Marketplace. Marketplaces may be
State Marketplaces, regional Marketplaces, subsidiary
Marketplaces, or the Federally-facilitated Marketplace.

When To File

single application or enroll in a single policy. See the
instructions for line 4 for more information about who is a
recipient.
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 is not
allowed on forms filed with the IRS.
Statements must be furnished on paper by mail, unless
the 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 consent on paper or electronically,
such as by e-mail. If consent is on paper, the recipient
must confirm the consent electronically. A statement may
be furnished electronically by e-mail or by informing the
recipient how to access the statement on a Marketplace’s
website.

Specific Instructions
Part I—Recipient Information
Line 1. Enter the Marketplace state name or
abbreviation.

File the annual report with the IRS and furnish the
statements to individuals on or before January 31, 2015,
for coverage in calendar year 2014.

Line 2. Enter the number the Marketplace assigned to
the policy.

The requirement to furnish a statement to individuals
will be met if the Form 1095-A is properly addressed and
mailed 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 is not a Saturday, Sunday, or legal holiday.

Line 4. Enter the name of the person (the recipient)
identified at enrollment who is expected to file a tax return
and who, if qualified, would claim the premium tax credit
for the year of coverage for his or her household.

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.

Line 6. Enter the recipient’s date of birth only if line 5 is
blank.

Furnishing required information to the individual.
Marketplaces may 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. Do not
file a Form 1095-A for a separate dental policy. See the
instructions for Part III, column A.
Furnish a separate Form 1095-A to each recipient,
including recipients for separate families who submit a
Aug 28, 2014

Line 3. Enter the name of the issuer of the policy.

Line 5. Enter the social security number (SSN) for the
recipient shown line 4.

Lines 7, 8, and 9. Enter information about the recipient’s
spouse, if any, only if advance credit payments were
made for the coverage. Enter a date of birth only if line 8 is
blank.
Lines 10 and 11. Enter the dates that coverage under
the policy started and ended. Enter on line 11 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
12/31/2014.
Lines 12-15. Enter the recipient's address.

Cat. No. 63016Q

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Part II—Coverage Household

enter the premiums for the SLCSP that would apply to all
individuals identified in Part II as covered for the month.
Leave column B blank if no advance credit payments are
made for the coverage and your state has provided a tool
for determining the applicable SLCSP for the year of
coverage at the time of filing the tax return.

Enter on lines 16 through 20 and columns A through E
information for each individual including the recipient and
the recipient's spouse covered under the policy. If
advance credit payments were made for the coverage on
a recipient’s behalf enter in Part II information only for
covered individuals for whom the recipient attested to the
Marketplace at enrollment the intention to claim a
personal exemption deduction on the tax return (recipient,
spouse, and dependents). If advance credit payments
were not made on behalf of a recipient enter in Part II
information for all covered individuals.

Column C. Enter the amount of advance credit payments
for the month.

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.

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 12/31/2014.

TIP

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 you are complying
with these laws and to allow us to figure and collect the
right amount of tax.

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

You are not 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 section 6103.

Part III—Household 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 the premium tax credit. Total the amounts on
lines 21 through 32 and enter on line 33.
Column A. Enter the total monthly premiums for the
policy in which the recipient or family members enrolled.
Include only the premiums allocable to essential health
benefits. However, include the premiums for a
stand-alone dental plan allocable to pediatric dental
coverage in the total monthly premium. If more than one
Form 1095-A is filed for coverage of the recipient’s family
for the same months, include the premium for pediatric
dental coverage in the amount in column A on only one
Form 1095-A.

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

.

Learning about the law or the
form . . . . . . . . . . . . . . . . . . . . . . . .

.

Preparing the form . . . . . . . . . . . .

.

Copying, assembling, and
sending the form to the IRS . . . . . .

Column B. Enter the premiums for the applicable second
lowest cost silver plan (SLCSP) used as a benchmark to
compute monthly advance credit payments. The
applicable SLCSP is the SLCSP that would cover only
individuals identified in Part II covered during the month
who were identified at enrollment as members of the
recipient’s family (the individuals who would be claimed
as personal exemption deductions on the recipient’s tax
return) and who are not eligible for other health coverage.
See Publication 974, Premium Tax Credit, for additional
information on eligibility for other health coverage. If no
advance credit payments are made for the coverage,

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
write to the Internal Revenue Service; Tax Forms and
Publications Division; SE:W:CAR:MP:T, 1111 Constitution
Ave. NW, IR-6526, Washington, DC 20224. Do not send
the form to this office. Instead, see Where To File, earlier.

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Instructions for Form 1095-A 2014