Form 1095-C Draft - Employer-Provided Health Insurance Offer And Covegate - 2017 Page 3

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DRAFT AS OF
600216
2
Form 1095-C (2017)
Page
Instructions for Recipient
Part II. Employer Offer of Coverage, Lines 14–16
August 14, 2017
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you
You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to
and your spouse and dependent(s), if any. (If you received an offer of coverage through a
the employer shared responsibility provision in the Affordable Care Act. This Form 1095-C includes
multiemployer plan due to your membership in a union, that offer may not be shown on line 14.) The
information about the health insurance coverage offered to you by your employer. Form 1095-C, Part
information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you,
II, includes information about the coverage, if any, your employer offered to you and your spouse and
your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.
dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace
1A. Minimum essential coverage providing minimum value offered to you with an employee required
and wish to claim the premium tax credit, this information will assist you in determining whether you
contribution for self-only coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states
are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit
single federal poverty line and minimum essential coverage offered to your spouse and dependent(s)
(PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were
DO NOT FILE
(referred to here as a Qualifying Offer). This code may be used to report for specific months for which a
Applicable Large Employers (for example, you left employment with one Applicable Large Employer
Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the
and began a new position of employment with another Applicable Large Employer). In that situation,
calendar year. For information on the adjustment of the 9.5%, see IRS.gov.
each Form 1095-C would have information only about the health insurance coverage offered to you by
the employer identified on the form. If your employer is not an Applicable Large Employer it is not
1B. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage NOT offered to your spouse or dependent(s).
required to furnish you a Form 1095-C providing information about the health coverage it offered.
1C. Minimum essential coverage providing minimum value offered to you and minimum essential
In addition, if you, or any other individual who is offered health coverage because of their
relationship to you (referred to here as family members), enrolled in your employer's health plan and
coverage offered to your dependent(s) but NOT your spouse.
that plan is a type of plan referred to as a "self-insured" plan, Form 1095-C, Part III provides
1D. Minimum essential coverage providing minimum value offered to you and minimum essential
information to assist you in completing your income tax return by showing you or those family
coverage offered to your spouse but NOT your dependent(s).
members had qualifying health coverage (referred to as "minimum essential coverage") for some or all
1E. Minimum essential coverage providing minimum value offered to you and minimum essential
months during the year.
coverage offered to your dependent(s) and spouse.
If your employer provided you or a family member health coverage through an insured health plan or
1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse
in another manner, the issuer of the insurance or the sponsor of the plan providing the coverage will
or dependent(s), or you, your spouse, and dependent(s).
furnish you information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if
1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-
you or a family member obtained minimum essential coverage from another source, such as a
insured employer-sponsored coverage for one or more months of the calendar year. This code will be
government-sponsored program, an individual market plan, or miscellaneous coverage designated by
entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on
the Department of Health and Human Services, the provider of that coverage will furnish you
line 14.
information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified
1H. No offer of coverage (you were NOT offered any health coverage or you were offered
health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report
coverage that is NOT minimum essential coverage).
information about that coverage on Form 1095-A, Health Insurance Marketplace Statement.
1I. Reserved.
Employers are required to furnish Form 1095-C only to the employee. As the recipient of
1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
TIP
this Form 1095-C, you should provide a copy to any family members covered under a
conditionally offered to your spouse; and minimum essential coverage NOT offered to your
self-insured employer-sponsored plan listed in Part III if they request it for their records.
dependent(s).
1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
Additional information. For additional information about the tax provisions of the Affordable Care Act
conditionally offered to your spouse; and minimum essential coverage offered to your dependent(s).
(ACA), including the individual shared responsibility provisions, the premium tax credit, and the
Line 15. This line reports the employee required contribution, which is the monthly cost to you for the
employer shared responsibility provisions, see
lowest-cost self-only minimum essential coverage providing minimum value that your employer offered
Families or call the IRS Healthcare Hotline for ACA questions (1-800-919-0452).
you. The amount reported on line 15 may not be the amount you paid for coverage if, for example, you
chose to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only
Part I. Employee
if code 1B, 1C, 1D, 1E, 1J, or 1K is entered on line 14. If you were offered coverage but there is no cost
Lines 1–6. Part I, lines 1–6, reports information about you, the employee.
to you for the coverage, this line will report a “0.00” for the amount. For more information, including on
how your eligibility for other healthcare arrangements might affect the amount reported on line 15, see
Line 2. This is your social security number (SSN). For your protection, this form may show only the last
IRS.gov.
four digits of your SSN. However, the employer is required to report your complete SSN to the IRS.
Line 16. This code provides the IRS information to administer the employer shared responsibility
!
provisions. Other than a code 2C which reflects your enrollment in your employer's coverage, none of
If you do not provide your SSN and the SSNs of all covered individuals to the plan
this information affects your eligibility for the premium tax credit. For more information about the
administrator, the IRS may not be able to match the Form 1095-C to determine that you
employer shared responsibility provisions, see IRS.gov.
and the other covered individuals have complied with the individual shared responsibility
CAUTION
provision. For covered individuals other than the employee listed in
Part III. Covered Individuals, Lines 17–22
Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. See Part III.
Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I),
Part I. Applicable Large Employer Member (Employer)
and coverage information about each individual (including any full-time employee and non-full-time
employee, and any employee's family members) covered under the employer's health plan, if the plan
Lines 7–13. Part I, lines 7–13, reports information about your employer.
is "self-insured." A date of birth will be entered in column (c) only if an SSN (or TIN for covered
Line 10. This line includes a telephone number for the person whom you may call if you have questions
individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be
about the information reported on the form or to report errors in the information on the form and ask
checked if the individual was covered for at least one day in every month of the year. For individuals
that they be corrected.
who were covered 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 6 covered individuals, see the
additional covered individuals on Part III, Continuation Sheet(s).

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