Instructions For Form 1095-A Draft - Health Insurance Marketplace Statement

amount in column A on only one Form 1095-A. If more

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

than one tax filer is enrolled in a policy, report on each tax

blank.

filer's Form 1095-A only those enrollment premiums

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

allocated to that tax filer. If a policy is terminated by an

spouse, if any, if advance credit payments were made for

issuer for nonpayment of premiums, enter -0- for a month

the coverage. Enter this information even if the advance

in which the covered individuals have coverage but the

credit payments weren't made for the spouse's coverage.

premiums aren't fully paid (generally, the first month of a

Enter a date of birth only if line 8 is blank.

grace period).

DRAFT AS OF

Lines 10 and 11. Enter the dates that coverage under

Column B. Enter the premiums for the applicable second

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

lowest cost silver plan (SLCSP) used as a benchmark to

termination if the policy was terminated during the year. If

compute monthly advance credit payments. If advance

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

credit payments are made, the applicable SLCSP for a

12/31/2015.

month is the SLCSP that applies to individuals in Part II

August 4, 2015

who were identified at enrollment as members of the tax

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

filer’s family (the individuals who would be claimed as

Part II—Covered Individuals

personal exemption deductions on the tax filer’s tax

return) and who are enrolled in the coverage on the first

Enter on lines 16 through 20 and columns A through E

day of the month and aren't eligible for other health

information for each individual covered under the policy,

coverage for that month. However, if a child is added to

including the recipient and the recipient's spouse, if

the family (through birth, adoption, or placement in foster

covered. If advance credit payments weren't made for any

care) and the child's coverage is effective on the date of

coverage under the policy and a tax household can't be

birth or other addition to the family, the applicable SLCSP

identified, enter in Part II information for all covered

premium includes the child for the entire month. If all

individuals. If advance credit payments were made for the

covered individuals enroll after the first of the month,

coverage or a tax household can be identified, enter in

enter -0- in column B for that month. If more than one

Part II information only for covered individuals who are

Form 1095-A is filed for coverage of a tax filer’s family for

members of the tax filer’s tax household (individuals for

the same months, a single SLCSP premium applies to all

whom the tax filer attested to the Marketplace at

the family members enrolled in any policy on the first of

enrollment the intention to claim a personal exemption

the month and not eligible for other health coverage in that

deduction on the tax return, that is the tax filer, spouse

month. Enter this single SLCSP premium in column B on

and dependents. Information about individuals enrolled in

each Form 1095-A.

the same policy as the tax filer’s tax household who aren't

members of that tax household, including children, must

If the information provided at enrollment doesn't

be reported on a separate Form 1095-A.

indicate which covered individuals are members of the

recipient's family and not eligible for the other health

For each line, enter a date of birth in column C only if

coverage (for example, because no financial assistance

column B is blank. Enter in column D the date the

was requested), enter the premiums for the SLCSP that

coverage started for the individual. Enter in column E the

would apply to all individuals identified in Part II as

date of termination if the individual's coverage was

covered for the month. However, leave column B blank if

terminated during the year. If the coverage was in effect at

your state has provided a tool for determining the

the end of the year, enter 12/31/2015.

applicable SLCSP for the year of coverage at the time of

filing the tax return.

If there are more than 5 covered individuals,

complete one or more additional Forms 1095-A,

If a policy is terminated by an issuer for nonpayment of

TIP

Part II.

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,

Part III—Coverage Information

the first month of a grace period). Enter the applicable

Enter information in Part III, lines 21 through 32, for each

SLCSP premium for the entire month even if the month of

month of coverage. This information is determined on a

termination is less than a full month.

monthly basis and may change during the year if there is a

change in enrollment or other circumstances that affect

Column C. Enter the amount of advance credit payments

eligibility for or the amount of the premium tax credit. Total

for the month. If more than one Form 1095-A is filed for

the amounts on lines 21 through 32 and enter on line 33.

coverage of a tax filer’s family for the same months, enter

only the advance credit payment amount allocated to the

Column A. Enter the total monthly enrollment premiums

policy reported on this Form 1095-A.

for the policy in which the covered individuals enrolled.

Include only the premiums allocable to essential health

Void Statements

benefits. If a covered individual enrolled in a stand-alone

If a Form 1095-A was sent for a policy that shouldn't be

dental plan, include the portion of the premiums for the

reported on a Form 1095-A, such as a separate dental

stand-alone dental plan that is allocable to pediatric dental

plan or a catastrophic health plan, send a duplicate of that

coverage in the total monthly enrollment premiums. If

Form 1095-A and check the void box at the top of the

more than one Form 1095-A is filed for coverage of the

form. Provide this information to the IRS and the

recipient’s family for the same months, because, for

statement recipient as soon as possible after discovering

example, a family member enrolled in a separate policy,

that the statement was sent in error.

include the premium for pediatric dental coverage in the

-2-

Instructions for Form 1095-A 2015

Instructions For Form 1095-A Draft - Health Insurance Marketplace Statement - 2015 Page 3

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