Form 1095-A - Health Insurance Marketplace Statement (Page 3 of 3) in pdf

Form 1095-A (2017)

Page

Instructions for Recipient

If advance credit payments are made, only the individuals for whom

you attested the intention to claim a personal exemption deduction

(yourself, spouse, and dependents) to the Marketplace at enrollment will

You received this Form 1095-A because you or a family member

be listed on Form 1095-A. If you attested to the Marketplace at

enrolled in health insurance coverage through the Health Insurance

enrollment that one or more of the individuals who enrolled in the plan

Marketplace. This Form 1095-A provides information you need to

aren’t individuals for whom you intend to claim a personal exemption

complete Form 8962, Premium Tax Credit (PTC). You must complete

deduction on your tax return, those individuals won’t be listed on your

Form 8962 and file it with your tax return (Form 1040, Form 1040A,

Form 1095-A. For example, if you indicated to the Marketplace at

or Form 1040NR) if any amount other than zero is shown in Part III,

enrollment that an individual enrolling in the policy is your adult child for

column C, of this Form 1095-A (meaning that you received premium

whom you won’t claim a personal exemption deduction, that child will

assistance through advance credit payments) or if you want to take

receive a separate Form 1095-A and won’t be listed in Part II on your

the premium tax credit. The filing requirement applies whether or not

Form 1095-A.

you’re otherwise required to file a tax return. If you are filing Form 8962,

you cannot file Form 1040EZ, Form 1040NR-EZ, Form 1040-SS, or

If advance credit payments are made and you attest that one or more

Form 1040-PR. The Marketplace also has reported the information on

enrolled individuals aren’t individuals for whom you intend to claim a

this form to the IRS. If you or your family members enrolled at the

personal exemption deduction, your Form 1095-A will include coverage

Marketplace in more than one qualified health plan policy, you will

information in Part III that is applicable solely to the individuals listed on

receive a Form 1095-A for each policy. Check the information on this

your Form 1095-A, and separately issued Forms 1095-A will include

form carefully. Please contact your Marketplace if you have questions

coverage information, including dollar amounts, applicable to those

concerning its accuracy. If you or your family members were enrolled in

individuals.

a Marketplace catastrophic health plan or separate dental policy, you

If advance credit payments weren’t made and you didn’t identify at

aren’t entitled to take a premium tax credit for this coverage when you

enrollment the individuals for whom you intended to claim a personal

file your return, even if you received a Form 1095-A for this coverage.

exemption deduction, Form 1095-A will list all enrolled individuals in

For additional information related to Form 1095-A, go to

Part II on your Form 1095-A.

Affordable-Care-Act/Individuals-and-Families/Health-Insurance-

Part II also tells the IRS the months that the individuals identified are

Marketplace-Statements.

covered by health insurance and therefore have satisfied the individual

Additional information. For additional information about the tax

shared responsibility provision.

provisions of the Affordable Care Act (ACA), including the individual

If there are more than 5 individuals covered by a policy, you will

shared responsibility provisions, the premium tax credit, and the

receive one or more additional Forms 1095-A that continue Part II.

employer shared responsibility provisions, see Affordable-

Care-Act/Individuals-and-Families or call the IRS Healthcare Hotline for

Part III. Coverage Information, lines 21–33. Part III reports information

ACA questions (1-800-919-0452).

about your insurance coverage that you will need to complete Form

8962 to reconcile advance credit payments or to take the premium tax

VOID box. If the “VOID” box is checked at the top of the form, you

credit when you file your return.

previously received a Form 1095-A for the policy described in Part I.

That Form 1095-A was sent in error. You shouldn’t have received a

Column A. This column is the monthly premiums for the plan in which

Form 1095-A for this policy. Don’t use the information on this or the

you or family members were enrolled, including premiums that you paid

previously received Form 1095-A to figure your premium tax credit on

and premiums that were paid through advance payments of the

Form 8962.

premium tax credit. If you or a family member enrolled in a separate

dental plan with pediatric benefits, this column includes the portion of

CORRECTED box. If the “CORRECTED” box is checked at the top of

the dental plan premiums for the pediatric benefits. If your plan covered

the form, use the information on this Form 1095-A to figure the premium

benefits that aren’t essential health benefits, such as adult dental or

tax credit and reconcile any advance credit payments on Form 8962.

vision benefits, the amount in this column will be reduced by the

Don’t use the information on the original Form 1095-A you received for

premiums for the non-essential benefits. If the policy was terminated by

this policy.

your insurance company due to nonpayment of premiums for one or

Part I. Recipient Information, lines 1–15. Part I reports information

more months, then a -0- will appear in this column for these months

about you, the insurance company that issued your policy, and the

regardless of whether advance credit payments were made for these

Marketplace where you enrolled in the coverage.

months.

Line 1. This line identifies the state where you enrolled in coverage

Column B. This column is the monthly premium for the second lowest

through the Marketplace.

cost silver plan (SLCSP) that the Marketplace has determined applies to

Line 2. This line is the policy number assigned by the Marketplace to

members of your family enrolled in the coverage. The applicable SLCSP

identify the policy in which you enrolled. If you are completing Part IV of

premium is used to compute your monthly advance credit payments

Form 8962, enter this number on line 30, 31, 32, or 33, box a.

and the premium tax credit you take on your return. See the instructions

for Form 8962, Part II, on how to use the information in this column or

Line 3. This is the name of the insurance company that issued your

how to complete Form 8962 if there is no information entered. If the

policy.

policy was terminated by your insurance company due to nonpayment

Line 4. You are the recipient because you are the person the

of premiums for one or more months, then a -0- will appear in this

Marketplace identified at enrollment who is expected to file a tax return

column for the months, regardless of whether advance credit payments

and who, if qualified, would take the premium tax credit for the year of

were made for these months.

coverage.

Column C. This column is the monthly amount of advance credit

Line 5. This is your social security number. For your protection, this

payments that were made to your insurance company on your behalf to

form may show only the last four digits. However, the Marketplace has

pay for all or part of the premiums for your coverage. If this is the only

reported your complete social security number to the IRS.

column in Part III that is filled in with an amount other than zero for a

Line 6. A date of birth will be entered if there is no social security

month, it means your policy was terminated by your insurance company

number on line 5.

due to nonpayment of premiums, and you aren’t entitled to take the

premium tax credit for that month when you file your tax return. You still

Lines 7, 8, and 9. Information about your spouse will be entered only if

must reconcile the entire advance payment that was paid on your behalf

advance credit payments were made for your coverage. The date of

for that month using Form 8962. No information will be entered in this

birth will be entered on line 9 only if line 8 is blank.

column if no advance credit payments were made.

Lines 10 and 11. These are the starting and ending dates of the policy.

Lines 21–33. The Marketplace will report the amounts in columns A, B,

Lines 12 through 15. Your address is entered on these lines.

and C on lines 21–32 for each month and enter the totals on line 33. Use

Part II. Covered Individuals, lines 16–20. Part II reports information

this information to complete Form 8962, line 11 or lines 12–23.

about each individual who is covered under your policy. This information

includes the name, social security number, date of birth, and the starting

and ending dates of coverage for each covered individual. For each line,

a date of birth is reported in column C only if an SSN isn’t entered in

column B.

Form 1095-A - Health Insurance Marketplace Statement Page 3

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