Form 1095-B - Health Coverege - 2017 (Page 2 of 2) in pdf

Instructions for Recipient

Line 8. This is the code for the type of coverage in which you or other

This Form 1095-B provides information needed to report on your income tax

covered individuals were enrolled. Only one letter will be entered on this line.

return that you, your spouse (if you file a joint return), and individuals you

claim as dependents had qualifying health coverage (referred to as "minimum

A. Small Business Health Options Program (SHOP)

essential coverage") for some or all months during the year. Individuals who

B. Employer-sponsored coverage

don't have minimum essential coverage and don't qualify for an exemption

C. Government-sponsored program

from this requirement may be liable for the individual shared responsibility

D. Individual market insurance

payment.

E. Multiemployer plan

Minimum essential coverage includes government-sponsored programs,

F. Other designated minimum essential coverage

eligible employer-sponsored plans, individual market plans, and other

coverage the Department of Health and Human Services designates as

If you or another family member received health insurance

minimum essential coverage. For more information on the requirement to

TIP

coverage through a Health Insurance Marketplace (also known as

have minimum essential coverage and what is minimum essential coverage,

see

an Exchange), that coverage will generally be reported on a

Shared-Responsibility-Provision.

Form 1095-A rather than a Form 1095-B. If you or another family member

received employer-sponsored coverage, that coverage may be reported on a

Providers of minimum essential coverage are required to furnish

Form 1095-C (Part III) rather than a Form 1095-B. For more information, see

only one Form 1095-B for all individuals whose coverage is

TIP

https://

reported on that form. As the recipient of this Form 1095-B, you

Health-Care-Information-Forms-for-Individuals.

should provide a copy to other individuals covered under the policy

if they request it for their records.

Line 9. Reserved.

Part II. Information about Certain Employer-Sponsored Coverage, lines

Additional information. For additional information about the tax provisions

10-15. If you had employer-sponsored health coverage, this part may

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

provide information about the employer sponsoring the coverage. This part

responsibility provisions, the premium tax credit, and the employer shared

may show only the last four digits of the employer's EIN. This part may also

responsibility provisions, see

be left blank, even if you had employer-sponsored health coverage. If this

and-Families or call the IRS Healthcare Hotline for ACA questions

part is blank, you do not need to fill in the information or return it to your

(1-800-919-0452).

employer or other coverage provider.

Part I. Responsible Individual, lines 1–9. Part I reports information about

Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports

you and the coverage.

information about the coverage provider (insurance company, employer

Lines 2 and 3. Line 2 reports your social security number (SSN) or other

providing self-insured coverage, government agency sponsoring coverage

taxpayer identification number (TIN), if applicable. For your protection, this

under a government program such as Medicaid or Medicare, or other

form may show only the last four digits. However, the coverage provider is

coverage sponsor). Line 18 reports a telephone number for the coverage

required to report your complete SSN or other TIN, if applicable, to the IRS.

provider that you can call if you have questions about the information

Your date of birth will be entered on line 3 only if line 2 is blank.

reported on the form.

Part IV. Covered Individuals, lines 23-28. This part reports the name, SSN

If you don't provide your SSN or other TIN and the SSNs or other

or other TIN, and coverage information for each covered individual. A date of

TINs of all covered individuals to the sponsor of the coverage,

birth will be entered in column (c) only if the SSN or other TIN isn't entered in

the IRS may not be able to match the Form 1095-B with the

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

CAUTION

individuals to determine that they have complied with the

least one day in every month of the year. For individuals who were covered

individual shared responsibility provision.

for some but not all months, information will be entered in column (e)

indicating the months for which these individuals were covered. If there are

more than six covered individuals, see Part IV, Continuation Sheet(s), for

information about the additional covered individuals.

Form 1095-B - Health Coverege - 2017 Page 2

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