Fillable Form 1095-A

Form 1095-A, which provides information needed to claim the tax credit, is needed by someone who purchased coverage through health insurance marketplaces.

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What is Form 1095-A?

Form 1095-A, officially the Health Insurance Marketplace Statement, contains information that is needed to help you validate the amount of advance payments of the premium tax credit (APTCs) you may have received. If you have not received APTCS, Form 1095-A may help to see if you are eligible to receive a premium tax credit.

The entire form contains information about the health plan’s coverage.

All the information about individuals who enroll in a qualified health plan through the Health Insurance Marketplace must be in this form and will then be reported to the Internal Revenue Service (IRS).

The filing of this form is not the responsibility of the consumer. The information in this form is exclusively for your records and must be on hand before you complete your return. The information in this form will also be used to complete Form 8962 which will tell you if you need to adjust the amount of tax credits upward or downward.

Filing your taxes before you obtain Form 1095-A can result in mistakes, and the IRS may send you a letter noting any discrepancies in your taxes.

How to fill out Form 1095-A?

Part I—Recipient Information

Line 1. Enter where the recipient enrolled in coverage through the Marketplace.

Line 2. Provide the policy number assigned by the Marketplace.

Line 3. Provide the name of the company that issued the policy.

Line 4. Provide the name of the recipient of the statement.

Line 5. Provide the social security number (SSN) for the recipient shown on line 4.

Line 6. If the recipient does not have SSN, fill this in with the recipient's birth date.

Line 7. If the recipient has a spouse, enter the recipient’s spouse's name.

Line 8. Provide the recipient’s spouse's social security number (SSN).

Line 9. If the recipient’s spouse does not have SSN, fill this in with the recipient’s

spouse's birth date.

Line 10. Provide the policy’s starting date.

Line 11. Provide the date of termination of the policy.

Lines 12–15. Provide the address of the recipient.

Part II—Covered Individuals

Lines 16a to 20a. Provide the name of each individual covered under the recipient’s policy.

Lines 16b to 20b. Enter the social security number (SSN) of each individual covered under the recipient’s policy.

Lines 16c to 20c. Enter the date of birth of each individual covered under the recipient’s policy.

Lines 16d to 20d. Enter the date the coverage started for each individual.

Lines 16e to 20e. Enter the date the coverage ended for each individual.

Part III—Coverage Information

Lines 21a to 32a. Enter the monthly enrollment premiums for the policy in which the covered individuals enrolled.

Enter the premiums of separate health plans such as a dental plan with pediatric benefits here. Nonessential benefits will be reduced in the amount to be entered here if there are nonessential benefits covered in your plan.

If the recipient failed to pay premiums for one or more months which resulted in termination, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.

Lines 21b to 32b. Enter the premiums for the applicable second-lowest-cost silver plan (SLCSP).

Lines 21c to 32c. Provide the amount of advance credit payments for each month. If no advance credit payments were made, no information will be entered here.

Line 33a.Add the amounts entered on lines 21a to 32a.

Line 33b.Add the amounts entered on lines 21b to 32b.

Line 33c.Add the amounts entered on lines 21c to 32c.

Tips:

If anything about your coverage or household is wrong, contact the Marketplace Call Center.

If you did not receive your Form 1095-A, you may access it from your online MyAccount on HealthCare.gov in the tax form section.

If you do not have online access to MyAccount, then you can create an account on HealthCare.gov to view Form 1095-A. If you experience any issue when creating your online account or Form 1095-A is not posted in your online account, contact the Marketplace Call Center.

For those consumers in Catastrophic plans, Medicaid plans, Child Health Plus, or the Essential Plan, you will not be issued with Form 1095-A because you are not eligible for the Premium Tax Credit (PTC).

If you moved and have not informed your provider of your address change, your form may be forwarded by the U.S. Postal Service if you have a forwarding order in place. If there is no forwarding order, your form cannot be delivered.

If different members of your household had different health plans, you updated your coverage information during the year, or you switched plans during the year, you may receive more than one Form 1095-A.

If you have more than one type of health insurance throughout the year, then you’ll get 1095-A forms from every provider who you had a Health Insurance Marketplace plan with.

Like all tax documents, keep copies of Form 1095-A for at least three years.

Besides Form 1095-A, it is possible that you will get other important tax forms. These are Forms 1095-B and 1095-C.

If you filed your tax return based on information on your 1095-A form and you later get a corrected form, you may need to file an amended tax return.

Complete all sections of IRS form 8962. Enter the enrollment premiums from Part III: Column A, line 33 (annual amount), and lines 21 to 32 (monthly amounts). Enter the second-lowest-cost Silver plan (SLCSP) premium from Part III: Column B, line 33 (annual amount), and lines 21 to 32 (monthly amounts). Enter the Advance payment of premium tax credit from Part III: Column C, line 33 (annual amount), and lines 21 to 32 (monthly amounts).

Table of Contents

Fillable Form 1095-A