Fillable 2015 Form 1095-B - Health Coverage (Page 2 of 3) in pdf

560215

Form 1095-B (2015)

Page

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

payment.

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

TIP

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,

see

Line 9. This line will be blank for 2015.

Shared-Responsibility-Provision.

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

TIP

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

CAUTION

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)

provision.

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.

2015 Form 1095-B - Health Coverage Page 2

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