Form 1095-A- Health Insurance Marketplace Statement

2017

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 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.
Aug 30, 2017

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

Cat. No. 63016Q

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.

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.

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.

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.
If there are more than 5 covered individuals,

TIP 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
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Instructions for Form 1095-A (2017)

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.

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.

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.

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

Void Statements

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

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.

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.

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.

Instructions for Form 1095-A (2017)

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