Form 1095-A Health Insurance Marketplace Statement

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.

Form

1095-A

Department of the Treasury
Internal Revenue Service

Part I

Health Insurance Marketplace Statement

VOID

▶ Do

▶ Go

not attach to your tax return. Keep for your records.
to www.irs.gov/Form1095A for instructions and the latest information.

OMB No. 1545-2232

CORRECTED

2017

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

C. Covered individual
date of birth

D. Coverage start date

E. Coverage termination date

16
17
18
19
20

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 (2017)

Form 1095-A (2017)

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 (Form 1040, Form 1040A,
or Form 1040NR) 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. If you are filing Form 8962,
you cannot file Form 1040EZ, Form 1040NR-EZ, Form 1040-SS, or
Form 1040-PR. The Marketplace also has 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-InsuranceMarketplace-Statements.
Additional information. For additional information about the tax
provisions of the Affordable Care Act (ACA), including the individual
shared responsibility provisions, the premium tax credit, and the
employer shared responsibility provisions, see www.irs.gov/AffordableCare-Act/Individuals-and-Families or call the IRS Healthcare Hotline for
ACA questions (1-800-919-0452).
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.

Page 2

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 are made and you attest that one or more
enrolled individuals aren’t individuals for whom you intend to claim a
personal exemption deduction, your Form 1095-A will include coverage
information in Part III that is applicable solely to the individuals listed on
your Form 1095-A, and separately issued Forms 1095-A will include
coverage information, including dollar amounts, applicable to those
individuals.
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.