Instructions For Form 1095-A - Health Insurance Marketplace Statement

2014

Department of the Treasury

Internal Revenue Service

Instructions for Form 1095-A

Health Insurance Marketplace Statement

Section references are to the Internal Revenue Code

single application or enroll in a single policy. See the

unless otherwise noted.

instructions for line 4 for more information about who is a

recipient.

Future Developments

On Form 1095-A statements furnished to recipients,

For the latest information about developments related to

filers of Form 1095-A may truncate the social security

Form 1095-A and its instructions, such as legislation

number (SSN) of an individual receiving coverage by

enacted after they were published, go to

showing only the last four digits of the SSN and replacing

form1095a.

the first five digits with asterisks (*) or Xs. Truncation is not

Additional Information

allowed on forms filed with the IRS.

Statements must be furnished on paper by mail, unless

For information related to the Affordable Care Act, visit

the recipient affirmatively consents to receive the

ACA.

statement in an electronic format. If mailed, the statement

must be sent to the recipient’s last known permanent

General Instructions

address, or if no permanent address is known, to the

recipient’s temporary address.

Purpose of Form

Consent to furnish statement electronically. The

Form 1095-A is used to report certain information to the

requirement to obtain affirmative consent to furnish a

IRS about family members who enroll in a qualified health

statement electronically ensures that statements are sent

plan through the Marketplace. Form 1095-A also is

Draft as of

electronically only to individuals who are able to access

furnished to individuals to allow them to claim the

them. A recipient may consent on paper or electronically,

premium tax credit, to reconcile the credit on their returns

such as by e-mail. If consent is on paper, the recipient

with advance payments of the premium tax credit

must confirm the consent electronically. A statement may

(advance credit payments), and to file an accurate tax

be furnished electronically by e-mail or by informing the

return.

recipient how to access the statement on a Marketplace’s

website.

Who Must File

Health Insurance Marketplaces must file Form 1095-A to

08/28/2014

Specific Instructions

report information on all enrollments in qualified health

plans through the Marketplace. Marketplaces may be

Part I—Recipient Information

State Marketplaces, regional Marketplaces, subsidiary

Marketplaces, or the Federally-facilitated Marketplace.

Line 1. Enter the Marketplace state name or

abbreviation.

When To File

Line 2. Enter the number the Marketplace assigned to

File the annual report with the IRS and furnish the

the policy.

statements to individuals on or before January 31, 2015,

for coverage in calendar year 2014.

Line 3. Enter the name of the issuer of the policy.

Line 4. Enter the name of the person (the recipient)

The requirement to furnish a statement to individuals

identified at enrollment who is expected to file a tax return

will be met if the Form 1095-A is properly addressed and

and who, if qualified, would claim the premium tax credit

mailed on or before the due date. If the regular due date

for the year of coverage for his or her household.

falls on a Saturday, Sunday, or legal holiday, furnish the

statement by the next business day. A business day is

Line 5. Enter the social security number (SSN) for the

any day that is not a Saturday, Sunday, or legal holiday.

recipient shown line 4.

Electronic filing. You must submit the information to the

Line 6. Enter the recipient’s date of birth only if line 5 is

IRS electronically. Submit the information through the

blank.

Department of Health and Human Services Data Services

Lines 7, 8, and 9. Enter information about the recipient’s

Hub.

spouse, if any, only if advance credit payments were

Furnishing required information to the individual.

made for the coverage. Enter a date of birth only if line 8 is

Marketplaces may use Form 1095-A to furnish the

blank.

required statement to recipients. A separate Form 1095-A

Lines 10 and 11. Enter the dates that coverage under

must be furnished for each policy and the information on

the policy started and ended. Enter on line 11 the date of

the Form 1095-A should relate only to that policy. Do not

termination if the policy was terminated during the year. If

file a Form 1095-A for a separate dental policy. See the

the policy was in effect at the end of the year, enter

instructions for Part III, column A.

12/31/2014.

Furnish a separate Form 1095-A to each recipient,

Lines 12-15. Enter the recipient's address.

including recipients for separate families who submit a

Aug 28, 2014

Cat. No. 63016Q

Instructions For Form 1095-A - Health Insurance Marketplace Statement - 2014 Page 2

Related Articles

Related forms

Related Categories