Instructions For Form 1095-A - Health Insurance Marketplace Statement

identified from the information provided at enrollment (for

benefits. If a covered individual is enrolled in a

example, because no financial assistance was

stand-alone dental plan, include the portion of the

requested), enter the name of the primary applicant for the

premiums for the stand-alone dental plan that is allocable

coverage.

to pediatric dental coverage in the total monthly

enrollment premiums. If more than one Form 1095-A is

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

filed for coverage of the recipient’s family for the same

recipient shown on line 4.

months, because, for example, a family member enrolled

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

in a separate policy, include the portion of the premium for

blank.

pediatric dental coverage in the amount in column A on

only one Form 1095-A. If more than one tax filer is

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

enrolled in a policy, report on each tax filer's Form 1095-A

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

only those enrollment premiums allocated to that tax filer.

the coverage. Enter this information even if the advance

If a policy is terminated by an issuer for nonpayment of

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

premiums, enter -0- for a month in which the covered

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

individuals have coverage but the premiums aren't fully

Line 10. Enter the date that coverage under the policy

paid (generally, the first month of a grace period). If one or

started. If the policy was in effect at the start of the year,

more covered individuals terminate coverage before the

enter 1/1/2017.

last day of a month, the amount reported in this column

should not include any amount of the monthly enrollment

Line 11. Enter the date of termination if the policy was

premium that was refunded.

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

end of the year, enter 12/31/2017.

Column B. Enter the premiums for the applicable second

lowest cost silver plan (SLCSP) that was used as a

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

benchmark to compute monthly advance credit payments.

Part II—Covered Individuals

If advance credit payments were made, the applicable

SLCSP for a month is the SLCSP that applies to

Enter on lines 16 through 20 and columns A through E

individuals in Part II who were identified at enrollment as

information for each individual covered under the policy,

members of the tax filer’s family (the individuals who

including the recipient and the recipient's spouse, if

would be claimed as personal exemption deductions on

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

the tax filer’s tax return) and who are enrolled in the

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

coverage on the first day of the month and aren't eligible

identified, enter in Part II information for all covered

for other health coverage for that month. However, if an

individuals. If advance credit payments were made for the

individual enrolls in coverage and the enrollment is

coverage or a tax household can be identified, enter in

effective on the date of the individual's birth, adoption,

Part II information only for covered individuals who are

placement in foster care, or on the effective date of a court

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

order, the individual should be considered to have

whom the tax filer attested to the Marketplace at

enrolled on the first day of the month for purposes of the

enrollment the intention to claim a personal exemption

applicable SLCSP premium reported in column B. If all

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

covered individuals enroll after the first of the month, and

and dependents. Information about individuals enrolled in

no individual's coverage is effective on the date of the

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

individual's birth, adoption, placement in foster care, or on

members of that tax household, including children, must

the effective date of a court order, enter -0- in column B

be reported on a separate Form 1095-A.

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

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

coverage of a tax filer’s family for the same month (for

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

example, because members of the family were split

coverage started for the individual. Enter in column E the

among several policies), enter the SLCSP premium that

date of termination if the individual's coverage was

applies to all the family members who were enrolled in any

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

policy on the first of the month and who were not eligible

the end of the year, enter 12/31/2017.

for other health coverage for that month. Enter this SLCSP

premium in column B on each Form 1095-A.

If there are more than 5 covered individuals,

In some cases, the information provided at enrollment

complete one or more additional Forms 1095-A,

TIP

may not indicate which covered individuals are members

Part II.

of the recipient's family and are not eligible for other health

coverage. (Such information may not be provided, for

Part III—Coverage Information

example, because no financial assistance was

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

requested.) If this is the case, and if the Marketplace has

month of coverage. This information is determined on a

provided a tool for determining the applicable SLCSP

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

premium for the year of coverage at the time of filing the

change in enrollment or other circumstances that affect

tax return, leave column B blank. If the Marketplace has

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

not provided a tool for determining the applicable SLCSP

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

premium, enter the premiums for the SLCSP that would

apply to all individuals identified in Part II as covered for

Column A. Enter the total monthly enrollment premiums

the month.

for the policy in which the covered individuals enrolled.

Include only the premiums allocable to essential health

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Instructions for Form 1095-A (2017)

Instructions For Form 1095-A - Health Insurance Marketplace Statement - 2017 Page 2

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