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

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Form 1095-B (2016)

Page

Instructions for Recipient

If you or another family member received health insurance

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coverage through a Health Insurance Marketplace (also known as

This Form 1095-B provides information needed to report on your income tax

an Exchange), that coverage will generally be reported on a

return that you, your spouse (if you file a joint return), and individuals you

Form 1095-A rather than a Form 1095-B. If you or another family member

claim as dependents had qualifying health coverage (referred to as “minimum

received employer-sponsored coverage, that coverage may be reported on a

essential coverage”) for some or all months during the year. Individuals who

Form 1095-C (Part III) rather than a Form 1095-B. For more information, see

don't have minimum essential coverage and don't qualify for an exemption

from this requirement may be liable for the individual shared responsibility

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payment.

Health-Care-Information-Forms-for-Individuals.

Minimum essential coverage includes government-sponsored programs,

Line 9. Reserved.

eligible employer-sponsored plans, individual market plans, and other

Part II. Information about Certain Employer-Sponsored Coverage, lines

coverage the Department of Health and Human Services designates as

10–15. If you had employer-sponsored health coverage, this part may

minimum essential coverage. For more information on the requirement to

provide information about the employer sponsoring the coverage. This part

have minimum essential coverage and what is minimum essential coverage,

may show only the last four digits of the employer's EIN. This part may also

see

be left blank, even if you had employer-sponsored health coverage. If this

Shared-Responsibility-Provision.

part is blank, you do not need to fill in the information or return it to your

Providers of minimum essential coverage are required to furnish

employer or other coverage provider.

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only one Form 1095-B for all individuals whose coverage is

Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports

reported on that form. As the recipient of this Form 1095-B, you

information about the coverage provider (insurance company, employer

should provide a copy to other individuals covered under the policy if they

providing self-insured coverage, government agency sponsoring coverage

request it for their records.

under a government program such as Medicaid or Medicare, or other

coverage sponsor). Line 18 reports a telephone number for the coverage

Part I. Responsible Individual, lines 1–9. Part I reports information about

provider that you can call if you have questions about the information

you and the coverage.

reported on the form.

Lines 2 and 3. Line 2 reports your social security number (SSN) or other

Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN

taxpayer identification number (TIN), if applicable. For your protection, this

or other TIN, and coverage information for each covered individual. A date of

form may show only the last four digits. However, the coverage provider is

birth will be entered in column (c) only if the SSN or other TIN isn't entered in

required to report your complete SSN or other TIN, if applicable, to the IRS.

column (b). Column (d) will be checked if the individual was covered for at

Your date of birth will be entered on line 3 only if line 2 is blank.

least one day in every month of the year. For individuals who were covered

for some but not all months, information will be entered in column (e)

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If you don't provide your SSN or other TIN and the SSNs or other TINs

indicating the months for which these individuals were covered. If there are

of all covered individuals to the sponsor of the coverage, the IRS may

more than six covered individuals, see Part IV, Continuation Sheet(s), for

not be able to match the Form 1095-B with the individuals to

CAUTION

information about the additional covered individuals.

determine that they have complied with the individual shared responsibility

provision.

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.

A. Small Business Health Options Program (SHOP)

B. Employer-sponsored coverage

C. Government-sponsored program

D. Individual market insurance

E . Multiemployer plan

F . Other designated minimum essential coverage

Form 1095-B, Health Coverage Page 2

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