Fillable Form 1095-A - Health Insurance Marketplace Statement

Form 1095-A (2015)

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

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

enrollment will be listed on Form 1095-A. If you attested to the

enrolled in health insurance coverage through the Health Insurance

Marketplace at enrollment that one or more of the individuals who

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

enrolled in the plan aren't individuals for whom you intend to claim a

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

personal exemption deduction on your tax return, those individuals

complete Form 8962 and file it with your tax return if any

won't be listed on your Form 1095-A. For example, if you indicated

amount other than zero is shown in Part III, Column C, of this

to the Marketplace at enrollment that an individual enrolling in the

Form 1095-A (meaning that you received premium assistance

policy is your adult child for whom you won't claim a personal

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

exemption deduction, that child will receive a separate Form 1095-A

premium tax credit. The filing requirement applies whether or not

and won't be listed in Part II on your Form 1095-A.

you're otherwise required to file a tax return. The Marketplace has

also reported the information on this form to the IRS. If you or your

If advance credit payments weren't made and you didn't identify

family members enrolled at the Marketplace in more than one

at enrollment the individuals for whom you intended to claim a

qualified health plan policy, you will receive a Form 1095-A for each

personal exemption deduction, Form 1095-A will list all enrolled

policy. Check the information on this form carefully. Please contact

individuals in Part II on your Form 1095-A.

your Marketplace if you have questions concerning its accuracy. If

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

you or your family members were enrolled in a Marketplace

are covered by health insurance and therefore have satisfied the

catastrophic health plan or separate dental policy, you aren't

individual shared responsibility provision.

entitled to take a premium tax credit for this coverage when you file

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

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

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

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

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

Insurance-Marketplace-Statements.

information about your insurance coverage that you will need to

complete Form 8962 to reconcile advance credit payments or to

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

take the premium tax 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

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

which you or family members were enrolled, including premiums

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

that you paid and premiums that were paid through advance

on Form 8962.

payments of the premium tax credit. If you or a family member

enrolled in a separate dental plan with pediatric benefits, this

CORRECTED box. If the "CORRECTED" box is checked at the top

column includes the portion of the dental plan premiums for the

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

pediatric benefits. If your plan covered benefits that aren't essential

premium tax credit and reconcile any advance credit payments on

health benefits, such as adult dental or vision benefits, the amount

Form 8962. Don't use the information on the original Form 1095-A

in this column will be reduced by the premiums for the non-

you received for this policy.

essential benefits. If the policy was terminated by your insurance

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

company due to nonpayment of premiums for one or more months,

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

then a -0- will appear in this column for these months regardless of

Marketplace where you enrolled in the coverage.

whether advance credit payments were made for these months.

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

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

through the Marketplace.

lowest cost silver plan (SLCSP) that the Marketplace has

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

determined applies to members of your family enrolled in the

to identify the policy in which you enrolled. If you are completing

coverage. The applicable SLCSP premium is used to compute your

Part IV of Form 8962, enter this number on line 30, 31, 32, or 33,

monthly advance credit payments and the premium tax credit you

box a.

take on your return. See the Instructions for Form 8962, Part II, on

how to use the information in this column or how to complete Form

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

8962 if there is no information entered. If the policy was terminated

policy.

by your insurance company due to nonpayment of premiums for

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

one or more months, then a -0- will appear in this column for the

Marketplace identified at enrollment who is expected to file a tax

months, regardless of whether advance credit payments were made

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

for these months.

the year of 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

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

behalf to pay for all or part of the premiums for your coverage. If this

has reported your complete social security number to the IRS.

is the only column in Part III that is filled in with an amount other

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

than zero for a month, it means your policy was terminated by your

number on line 5.

insurance company due to nonpayment of premiums, and you

aren't entitled to take the premium tax credit for that month when

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

you file your tax return. You still must reconcile the entire advance

only if advance credit payments were made for your coverage. The

payment that was paid on your behalf for that month using Form

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

8962. No information will be entered in this column if no advance

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

credit payments were made.

policy.

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

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

B, and C on lines 21–32 for each month and enter the totals on line

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

33. Use this information to complete Form 8962, line 11 or lines

information about each individual who is covered under your policy.

12–23.

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 - 2015 Page 2

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