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(except insurance substantially all of the

to your health plan for coverage for your

e. Your health plan identification

coverage of which is of excepted benefits

January coverage. The $25 you paid for

number(s).

described in section 9832(c)) and the

dental benefits is ineligible for the HCTC.

*If your health plan does not provide

employer paid 50% or more of the cost of

You would include the $200 you paid for

members with an insurance bill or COBRA

the coverage; or

your basic insurance on line 2.

payment coupon, you must provide health

2. You were an eligible ATAA or

Example 2. You checked December

plan enrollment documents or an official

RTAA recipient and either of the following

on line 1. You participated in the advance

letter from your health plan that has the

applies.

monthly payment program and paid only

required information listed under items 2a

$88 (27.5%) of your $320 December

a. You were eligible for qualified

through 2e earlier. If your monthly

premium. You received a Form 1099-H

health insurance coverage (including any

premium includes amounts that do not

showing an advance payment of $232

employer-sponsored health insurance

count towards the HCTC, such as dental

(72.5% of the $320 premium) for your

plan of your spouse) (other than the

or vision coverage or coverage for family

December coverage. You would not

coverage listed under item 3, 4a, or 4e in

members who are not eligible for the

include any part of the December

the definition of

Qualified Health Insurance

HCTC, your documentation must also

coverage premium on line 2 because you

Coverage) where the employer would

specify those ineligible amounts.

already received the benefit of the

have paid 50% or more of the cost of the

3. Proof of payment for each month

advance monthly payment program for

coverage; or

you are claiming the credit on line 2 such

December. You must still file Form 8885 to

b. You were covered under any

as:**

elect the HCTC for December.

qualified health insurance coverage

a. Canceled checks (copy of front and

(including any employer-sponsored health

Line 5

back),

insurance plan of your spouse) (other than

b. Bank statements,

If the resulting amount is zero or blank,

the coverage listed under item 3, 4a, or 4e

you can’t claim the HCTC on your income

c. Credit card statements, or

in the definition of

Qualified Health

tax return. However, you must still file

Insurance

Coverage) and the employer

d. Money orders.

Form 8885 to elect the HCTC for any

paid any part of the cost of the coverage.

**Your proof of payment must indicate

months you participated in the advance

Any amounts contributed to the

the amount paid and to whom it was paid.

monthly payment program.

cost of coverage by you or your

If you do not have one of these types of

spouse on a pre-tax basis are

Required Documents

proof of payment, contact your health plan

CAUTION

considered to have been paid by the

for a record of your payment(s).

If you claim any HCTC on line 5, you must

employer.

provide verifiable proof for each month

COBRA coverage. You must include

you are claiming the credit on line 2 that

Example. You had health insurance

the information under

All health plans

and

your health insurance coverage is

one of the following documents.

coverage under an employer-sponsored

qualified health insurance coverage for the

health insurance plan as of October 1. The

1. A copy of your completed and

HCTC and that you paid premiums for the

employer paid 40% of the cost of the

signed COBRA Election Letter. It may also

qualified health insurance coverage by

coverage. You paid 60% of the cost of the

be called a COBRA Enrollment Form,

attaching the documents listed below to

coverage through pre-tax contributions.

Application Form, Enrollment Application

your Form 8885. No documents are

You cannot take the HCTC for the month

for Continuing Coverage, or Election

required if you file Form 8885 only to elect

of October because the employer is

Agreement.

the HCTC for months you participated in

considered to have paid 100% of the cost

2. A letter from your former employer

the advance monthly payment program.

of the coverage.

or COBRA administrator saying you have

All health plans. For all health plans

COBRA coverage. The letter must have:

Line 2

you must include all of the following

a. The COBRA coverage start and

documents.

If your qualified health insurance

end dates;

1. An official letter reflecting that you

coverage covers anyone other

b. Name of the health plan;

were an eligible individual for the months

than you and your qualifying family

CAUTION

c. Your home address; and

claimed on line 2 in 2016:

members, see Pub. 502, Medical and

For trade certified individuals

Dental Expenses, before completing

d. Covered family members, their

demonstrating TAA, ATAA, or RTAA

line 2, to determine which amounts are

dates of birth, their relationship to you, and

eligibility — a copy of the official letter from

considered to be paid for coverage for you

their social security numbers.

the Department of Labor, your state

and your qualifying family members.

3. A copy of “Notice of Rights to

workforce agency, or employment office

Continue Coverage.”

Enter the total amount of insurance

stating you are eligible for trade

premiums paid by you for coverage for

Coverage through your spouse’s

adjustment benefits.

you and all qualifying family members

employer. You must include the

For PBGC eligibility — a copy of the

under

qualified health insurance coverage

information under

All health plans

and the

official letter or a copy of your 2016 Form

for all eligible coverage months checked

following documents.

1099-R from the PBGC showing you

on line 1. But do not include any insurance

Copies of paycheck stubs showing the

received a benefit paid by the PBGC.

premiums paid by you for eligible

health coverage deductions for each

2. A copy of your health insurance

coverage months for which you received

month you are claiming the credit on

bills or COBRA payment coupons for each

the benefit of the advance monthly

line 2.

month you are claiming the credit on

payment program. Also, do not include

A letter or other statement from your

line 2.* The bills must have:

any advance monthly payments your

spouse’s employer that states the

a. Your name (or name of the policy

health plan administrator received from

employer contributed less than 50% of the

the IRS, as shown on Form 1099-H, box 1.

holder),

cost of the coverage (TAA recipients and

b. The name of your health plan,

PBGC payees) or made no contributions

Example 1. You checked January on

to the cost of coverage (ATAA and RTAA

line 1. You paid $225 ($200 for basic

c. Your monthly premium amount,

recipients).

coverage and $25 for dental benefits

d. Dates of coverage, and

which are purchased separately) directly

Instructions for Form 8885 (2016)

Instructions For Form 8885 - Health Coverage Tax Credit - Internal Revenue Service - 2016 Page 4

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