Instructions For Forms 1094-C And 1095-C - 2017 (Page 13 of 17) in pdf

group health plan. If an ALE Member offers both insured and

calendar months. The employer must report for these individuals

self-insured coverage, complete Part III only for employees who

using Form 1095-B, if it chooses not to use Form 1095-C.

enroll in the self-insured coverage.

If a non-employee individual enrolls in the coverage

under a self-insured health plan, all family members that

An ALE Member with a self-insured major medical plan and a

TIP

are covered individuals because of the individual’s

health reimbursement arrangement (HRA) that has an individual

enrollment must be included on the same Form 1095-B or Form

who enrolls in both types of minimum essential coverage is

1095-C as the individual who is offered, and enrolls in, the

required to report the individual’s coverage under only one of the

coverage.

arrangements in Part III. An ALE Member with an insured major

medical plan and an HRA that has an individual who enrolls in

both types of minimum essential coverage is not required to

Columns (a) through (e), as applicable, must be completed

report in Part III the HRA coverage of an individual if the

for each individual enrolled in the coverage, including the

individual is eligible for the HRA because the individual enrolled

employee reported on line 1. Enter the nine-digit SSN or other

in the insured major medical plan. An ALE Member with an HRA

TIN for each covered individual in column (b). Enter a date of

must report coverage under the HRA in Part III for any individual

birth in column (c) only if an SSN or other TIN is not entered in

who is not enrolled in a major medical plan of the ALE Member

column (b). Column (d) will be checked if the individual was

(for example, if the individual is enrolled in a group health plan of

covered for at least one day in every month of the year. For

another employer (such as spousal coverage)). For additional

individuals who were covered for some but not all months,

information on the reporting of supplemental coverage, see

information will be entered in column (e) indicating the months

Proposed Regulations section 1.6055-1(d)(2) and (3).

for which these individuals were covered. If there are more than

6 covered individuals, complete this information on the

If the ALE Member is completing Part III, enter “X” in the

additional covered individuals on Part III Covered Individuals —

check box in Part III. If the ALE Member is not completing Part III,

Continuation Sheet(s). Do not count the continuation sheet(s) as

do not enter “X” in the check box in Part III.

additional Forms 1095-C in the count of forms submitted with the

accompanying Form 1094-C.

This part must be completed by an ALE Member offering

self-insured health coverage for any individual who was an

Governmental Unit employers offering self-insured

employee for one or more calendar months of the year, whether

health coverage that have delegated another

TIP

full-time or non-full-time, and who enrolled in the coverage. The

governmental unit (DGE) for purposes of reporting and

employee (if enrolled in self-insured coverage) should be listed

furnishing enrollment information (meaning the information that

on line 17; any other family members who enrolled in coverage

otherwise would be reported on Form 1095-C, Part III), but have

offered to the employee should be listed on subsequent lines.

not designated a DGE for purposes of reporting and furnishing

offer of coverage information (meaning the information that is

All employee family members that are covered

reported on Form 1095-C, Part II), should file and furnish Forms

individuals through the employee’s enrollment (for

TIP

1095-C with a completed Part I and Part II, but not a completed

example, because the employee elected family

Part III, and should not check the box indicating that the

coverage) must be included on the same form as the employee

Governmental Unit offers self-insured health coverage. In

(or any other individual to whom the offer was made). For

this case, the DGE should file Forms 1094-B and 1095-B to

example, if the employee is offered family coverage by his or her

report enrollment information for employees on behalf of the

employer under a self-insured health plan and enrolls in the

Governmental Unit. See FAQs on IRS.gov.

family coverage, the employee and the employee’s family

members that are covered under the plan must all be reported

on the same Form 1095-C.

A DGE that has been delegated by a Governmental Unit for

purposes of reporting and furnishing both offer of coverage and

enrollment information (meaning the information that would be

If two or more employees employed by the same ALE

reported on Parts II and III of Form 1095-C) should file Forms

Member are spouses or an employee and his or her dependent,

1094-C and 1095-C to report the information for employees on

and one employee enrolled in a coverage option under the plan

behalf of the Governmental Unit.

that also covered the other employee(s) (for example, one

employee spouse enrolled in family coverage that provided

Column (a). Enter the name of each covered individual

coverage to the other employee spouse and their employee

(including the employee, if the employee is enrolled in

dependent child), the enrollment information should be reflected

self-insured coverage).

only on Form 1095-C for the employee who enrolled in the

Column (b). Enter the 9-digit SSN for each covered individual,

coverage. (However, it would report the other employee family

including the dashes. For covered individuals who are not the

members as covered individuals).

employee listed in Part I, a taxpayer identification number (TIN),

Coverage of Non-Employee. This part may be completed by

rather than an SSN, may be entered if the covered individual

an ALE Member offering self-insured health coverage for any

does not have an SSN, or the field may be left blank if the

other individual who enrolled in the coverage under the plan for

covered individual does not have a TIN.

one or more calendar months of the year but was not an

Column (c). Enter a date of birth (YYYY-MM-DD) for the

employee for any calendar month of the year, such as a

covered individual only if column (b) is blank.

non-employee director, a retired employee who retired in a

previous year, a terminated employee receiving COBRA

Column (d). Check this box if the individual was covered for at

continuation coverage (or any other form of post-employment

least one day per month for all 12 months of the calendar year.

coverage) who terminated employment during a previous year,

Column (e). If the individual was not covered for all 12 months

and a non-employee COBRA beneficiary (but not including an

of the calendar year, check the applicable box(es) for the

individual who obtained coverage through the employee’s

month(s) in which the individual was covered for at least one day

enrollment, such as a spouse or dependent obtaining coverage

in the month.

when an employee elects COBRA continuation coverage that is

family coverage). If Form 1095-C is used with respect to an

Definitions

individual who was not an employee for any month of the

calendar year, Part II must be completed by using code 1G in the

This section contains the definitions of key terms used in Forms

“All 12 Months” box or the separate monthly boxes for all 12

1094-C and 1095-C and these instructions. For definitions of

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Instructions for Forms 1094-C and 1095-C (2017)

Instructions For Forms 1094-C And 1095-C - 2017 Page 13

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