Department of the Treasury
Internal Revenue Service
Instructions for Form 1095-A
Health Insurance Marketplace Statement
Section references are to the Internal Revenue Code
Statements to Individuals
unless otherwise noted.
Furnishing required information to the individual.
Marketplaces use Form 1095-A to furnish the required
statement to recipients. A separate Form 1095-A must be
For the latest information about developments related to
furnished for each policy and the information on the Form
Form 1095-A and its instructions, such as legislation
1095-A should relate only to that policy. If two or more tax
enacted after they were published, go to
filers are enrolled in one policy, each tax filer receives a
statement reporting coverage of only the members of that
tax filer's tax household. See the instructions for line 4 for
more information about who is a recipient. Don't furnish a
For information related to the Affordable Care Act, visit
Form 1095-A for a catastrophic health plan or a
stand-alone dental plan. See the instructions for Part III,
For additional information related to Form 1095-A, visit
On Form 1095-A statements furnished to recipients,
filers of Form 1095-A may truncate the social security
number (SSN) of an individual receiving coverage by
showing only the last four digits of the SSN and replacing
the first five digits with asterisks (*) or Xs. Truncation isn't
Purpose of Form
allowed on forms filed with the IRS.
Statements must be furnished to recipients on paper by
Form 1095-A is used to report certain information to the
IRS about individuals who enroll in a qualified health plan
mail, unless a recipient affirmatively consents to receive
the statement in an electronic format. If mailed, the
through the Health Insurance Marketplace. Form 1095-A
also is furnished to individuals to allow them to take the
statement must be sent to the recipient’s last known
permanent address, or if no permanent address is known,
premium tax credit, to reconcile the credit on their returns
with advance payments of the premium tax credit
to the recipient’s temporary address.
(advance credit payments), and to file an accurate tax
Consent to furnish statement electronically. The
requirement to obtain affirmative consent to furnish a
statement electronically ensures that statements are sent
Who Must File
electronically only to individuals who are able to access
Health Insurance Marketplaces must file Form 1095-A to
them. A recipient may provide his or her consent on paper
report information on all enrollments in qualified health
or electronically, such as by e-mail. If consent is provided
plans in the individual market through the Marketplace. Do
on paper, the recipient must confirm the consent
not file a Form 1095-A for a catastrophic health plan or a
electronically. An electronic statement may be furnished
separate dental policy (called a “stand-alone dental plan”
by e-mail or by informing the recipient how to access the
in these instructions).
statement on a Marketplace’s website (for example, in the
recipient's Marketplace account).
When To File
File the annual report with the IRS and furnish the
statements to individuals on or before January 31, 2018,
for coverage in calendar year 2017.
Part I—Recipient Information
The requirement to furnish a statement to individuals
Line 1. Enter the Marketplace state name or
will be met if the Form 1095-A is properly addressed and
mailed or furnished electronically (if the recipient has
consented to electronic receipt) on or before the due date.
Line 2. Enter the number the Marketplace assigned to
If the regular due date falls on a Saturday, Sunday, or
the policy. If the policy number is greater than 15
legal holiday, furnish the statement by the next business
characters, enter only the last 15 characters.
day. A business day is any day that isn't a Saturday,
Line 3. Enter the name of the issuer of the policy.
Sunday, or legal holiday.
Line 4. Enter the name of the recipient of the statement.
How To File
This should be the person identified at enrollment as the
tax filer (the person who is expected to file a tax return, to
Electronic filing. You must submit the information to the
claim other family members as dependents, and who, if
IRS electronically. Submit the information through the
qualified, would take the premium tax credit for the year of
Department of Health and Human Services Data Services
coverage for his or her household). If the tax filer can't be
Aug 30, 2017
Cat. No. 63016Q