2015 Form 1095-B - Health Coverage Page 2

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Form 1095-B (2015)
Instructions for Recipient
Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
This Form 1095-B provides information needed to report on your income tax
A. Small Business Health Options Program (SHOP)
return that you, your spouse (if you file a joint return), and individuals you
B. Employer-sponsored coverage
claim as dependents had qualifying health coverage (referred to as “minimum
C. Government-sponsored program
essential coverage”) for some or all months during the year. Individuals who
D. Individual market insurance
don't have minimum essential coverage and don't qualify for an exemption
E . Multiemployer plan
from this requirement may be liable for the individual shared responsibility
F . Other designated minimum essential coverage
Minimum essential coverage includes government-sponsored programs,
If you or another family member received health insurance
eligible employer-sponsored plans, individual market plans, and other
coverage through a Health Insurance Marketplace (also known as
coverage the Department of Health and Human Services designates as
an Exchange), that coverage will be reported on a Form 1095-A
minimum essential coverage. For more information on the requirement to
rather than a Form 1095-B.
have minimum essential coverage and what is minimum essential coverage,
Line 9. This line will be blank for 2015.
Part II. Employer-Sponsored Coverage, lines 10–15. This part will be
completed by the insurance company if an insurance company provides your
Providers of minimum essential coverage are required to furnish
employer-sponsored health coverage. It provides information about the
only one Form 1095-B for all individuals whose coverage is
employer sponsoring the coverage. This part may show only the last four
reported on that form. As the recipient of this Form 1095-B, you
digits of the employer's EIN. If your coverage isn't insured employer
should provide a copy to other individuals covered under the policy if they
coverage, this part will be blank.
request it for their records.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
Part I. Responsible Individual, lines 1–9. Part I reports information about
information about the coverage provider (insurance company, employer
you and the coverage.
providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
coverage sponsor). Line 18 reports a telephone number for the coverage
taxpayer identification number (TIN), if applicable. For your protection, this
provider that you can call if you have questions about the information
form may show only the last four digits. However, the coverage provider is
reported on the form.
required to report your complete SSN or other TIN, if applicable to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
or other TIN, and coverage information for each covered individual. A date of
If you don't provide your SSN or other TIN and the SSNs or other TINs
birth will be entered in column (c) only if SSN or other TIN isn't entered in
of all covered individuals to the sponsor of the coverage, the IRS may
column (b). Column (d) will be checked if the individual was covered for at
not be able to match the Form 1095-B with the individuals to
least one day in every month of the year. For individuals who were covered
determine that they have complied with the individual shared responsibility
for some but not all months, information will be entered in column (e)
indicating the months for which these individuals were covered. If there are
more than six covered individuals, see Part IV, Continuation Sheet(s), for
information about the additional covered individuals.


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