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IRS 1095-A Sample

CAUTION: NOT FOR FILING

Form 1095-A is provided here for informational purposes only.

Health Insurance Marketplaces use Form 1095-A to report information on enrollments in a qualified health plan in the individual market through the Marketplace. As the form is to be completed by the Marketplaces, individuals cannot complete and use Form 1095-A available on IRS.gov. Individuals receiving a completed Form 1095-A from the Health Insurance Marketplace will use the information received on the form and the guidance in the instructions to assist them in filing an accurate tax return.

Form 1095-A

Department of the Treasury Internal Revenue Service

Health Insurance Marketplace Statement

▶ Do not attach to your tax return. Keep for your records.

▶Go to www.irs.gov/Form1095A for instructions and the latest information.

VOID

CORRECTED

OMB No. 1545-2232

2021

 

Recipient Information

 

 

 

 

 

 

Part I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

Marketplace identifier

2

Marketplace-assigned policy number

3

Policy issuer’s name

 

 

 

 

 

 

 

 

 

 

4

Recipient’s name

 

 

5

Recipient’s SSN

6

Recipient’s date of birth

 

 

 

 

 

 

 

 

7

Recipient’s spouse’s name

 

 

8

Recipient’s spouse’s SSN

9

Recipient’s spouse’s date of birth

 

 

 

 

 

 

 

10

Policy start date

11

Policy termination date

12

Street address (including apartment no.)

 

 

 

 

 

 

 

13

City or town

14

State or province

15

Country and ZIP or foreign postal code

 

 

 

 

 

 

 

 

 

 

 

 

Covered Individuals

 

 

 

 

 

 

 

 

Part II

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Covered individual name

B. Covered individual SSN

C. Covered individual

 

D. Coverage start date

E. Coverage termination date

 

 

 

 

 

 

 

date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16

 

 

 

 

 

 

 

 

 

 

 

 

17

 

 

 

 

 

 

 

 

 

 

 

 

18

 

 

 

 

 

 

 

 

 

 

 

 

19

 

 

 

 

 

 

 

 

 

 

 

 

20

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coverage Information

 

 

 

 

 

 

 

 

Part III

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

A. Monthly enrollment premiums

B. Monthly second lowest cost silver

C. Monthly advance payment of

 

 

 

 

 

plan (SLCSP) premium

 

 

 

premium tax credit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21

January

 

 

 

 

 

 

 

 

 

22

February

 

 

 

 

 

 

 

 

 

23

March

 

 

 

 

 

 

 

 

 

 

24

April

 

 

 

 

 

 

 

 

 

 

25

May

 

 

 

 

 

 

 

 

 

 

26

June

 

 

 

 

 

 

 

 

 

 

27

July

 

 

 

 

 

 

 

 

 

 

28

August

 

 

 

 

 

 

 

 

 

 

29

September

 

 

 

 

 

 

 

 

 

30

October

 

 

 

 

 

 

 

 

 

31

November

 

 

 

 

 

 

 

 

 

32

December

 

 

 

 

 

 

 

 

 

33

Annual Totals

 

 

 

 

 

 

 

 

 

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60703Q

 

Form 1095-A (2021)

Form 1095-A (2021)

Page 2

Instructions for Recipient

You received this Form 1095-A because you or a family member enrolled in health insurance coverage through the Health Insurance Marketplace. This Form 1095-A provides information you need to complete Form 8962, Premium Tax Credit (PTC). You must complete

Form 8962 and file it with your tax return (Form 1040, Form

1040-SR, or Form 1040-NR) if any amount other than zero is shown in Part III, column C, of this Form 1095-A (meaning that you received premium assistance through advance payments of the premium tax credit (also called advance credit payments)) or if you want to take the premium tax credit. The filing requirement applies whether or not you’re otherwise required to file a tax return. If you are filing Form 8962, you cannot file Form 1040-NR-EZ, Form

1040-SS, or Form 1040-PR. The Marketplace has also reported the information on this form to the IRS. If you or your family members enrolled at the Marketplace in more than one qualified health plan policy, you will receive a Form 1095-A for each policy. Check the information on this form carefully. Please contact your Marketplace if you have questions concerning its accuracy. If you or your family members were enrolled in a Marketplace catastrophic health plan or separate dental policy, you aren’t entitled to take a premium tax credit for this coverage when you file your return, even if you received a Form 1095-A for this coverage. For additional information related to Form 1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- Families/Health-Insurance-Marketplace-Statements.

Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the premium tax credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or call the IRS Healthcare Hotline for ACA questions (800-919-0452).

VOID box. If the “VOID” box is checked at the top of the form, you 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 Form 1095-A for this policy. Don’t use the information on this or the previously received Form 1095-A to figure your premium tax credit on Form 8962.

CORRECTED box. If the “CORRECTED” box is checked at the top of the form, use the information on this Form 1095-A to figure the premium tax credit and reconcile any advance credit payments on Form 8962. Don’t use the information on the original Form 1095-A you received for this policy.

Part I. Recipient Information, lines 1–15. Part I reports information about you, the insurance company that issued your policy, and the Marketplace where you enrolled in the coverage.

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

Line 2. This line is the policy number assigned by the Marketplace to identify the policy in which you enrolled. If you are completing Part IV of Form 8962, enter this number on line 30, 31, 32, or 33, box a.

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

Line 4. You are the recipient because you are the person the Marketplace identified at enrollment who is expected to file a tax return and who, if qualified, would take the premium tax credit for the year of coverage.

Line 5. This is your social security number (SSN). For your protection, this form may show only the last four digits. However, the Marketplace has reported your complete SSN to the IRS.

Line 6. A date of birth will be entered if there is no SSN on line 5.

Lines 7, 8, and 9. Information about your spouse will be entered only if advance credit payments were made for your coverage. The date of birth will be entered on line 9 only if line 8 is blank.

Lines 10 and 11. These are the starting and ending dates of the policy. Lines 12 through 15. Your address is entered on these lines.

Part II. Covered Individuals, lines 16–20. Part II reports information about each individual who is covered under your policy. This information includes the name, SSN, 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.

If advance credit payments are made, the only individuals listed on Form 1095-A will be those whom you certified to the Marketplace would be in your tax family for the year of coverage (yourself, spouse, and dependents). If you certified to the Marketplace at enrollment that one or more of the individuals who enrolled in the plan aren’t individuals who would be in your tax family for the year of coverage, those individuals won’t be listed on your Form 1095-A. For example, if you indicated to the Marketplace at enrollment that an individual enrolling in the policy is your adult child who will not be your dependent for the year of coverage, that child will receive a separate Form 1095-A and won’t be listed in Part II on your Form 1095-A.

If advance credit payments are made and you certify that one or more enrolled individuals aren’t individuals who would be in your tax family for the year of coverage, your Form 1095-A will include coverage information in Part III that is applicable solely to the individuals listed on your Form 1095-A, and separately issued Forms 1095-A will include coverage information, including dollar amounts, applicable to those individuals not in your tax family.

If advance credit payments weren’t made and you didn’t identify at enrollment the individuals who would be in your tax family for the year of coverage, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A.

If there are more than 5 individuals covered by a policy, you will receive one or more additional Forms 1095-A that continue Part II.

Part III. Coverage Information, lines 21–33. Part III reports information about your insurance coverage that you will need to complete Form 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return.

Column A. This column is the monthly premiums for the plan in which you or family members were enrolled, including premiums that you paid and premiums that were paid through advance payments of the premium tax credit. If you or a family member enrolled in a separate dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered benefits that aren’t essential health benefits, such as adult dental or vision benefits, the amount in this column will be reduced by the premiums for the nonessential benefits. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.

Column B. This column is the monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined applies to members of your family enrolled in the coverage. The applicable SLCSP premium is used to compute your monthly advance credit payments and the premium tax credit you 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 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for the months, regardless of whether advance credit payments were made for these months.

Column C. This column is the monthly amount of advance credit payments that were made to your insurance company on your behalf to pay for all or part of the premiums for your coverage. If this is the only column in Part III that is filled in with an amount other than zero for a month, it means your policy was terminated by your insurance company due to nonpayment of premiums, and you aren’t entitled to take the premium tax credit for that month when you file your tax return. You must still reconcile the entire advance payment that was paid on your behalf for that month using Form 8962. No information will be entered in this column if no advance credit payments were made.

Lines 21–33. The Marketplace will report the amounts in columns A, B, and C on lines 21–32 for each month and enter the totals on line 33. Use this information to complete Form 8962, line 11 or lines 12–23.

⇓ PDF File

Instructions on Utilizing IRS 1095-A

After receiving your IRS 1095-A form, it's time to fill it out carefully. This form provides essential information for your tax return, particularly if you had health coverage through the Health Insurance Marketplace. Follow the steps below to complete it accurately.

  1. Gather your documents. Have your 1095-A form, Social Security number, and any other relevant tax documents handy.
  2. Locate the "Part I" section on the form. This part includes information about you and your household members who had coverage.
  3. Fill in your name, Social Security number, and the address where you reside. Ensure that the information matches your tax records.
  4. Move to "Part II." Here, you will find information about the coverage you had. Look for the columns labeled "Monthly Premium Amount" and "Second Lowest Cost Silver Plan (SLCSP) Premium Amount."
  5. Enter the monthly premium amounts for each month you were covered. If you had coverage for the entire year, fill in all twelve months.
  6. Next, find the SLCSP amounts. You will need these figures for your tax return, so make sure they are accurate.
  7. Check "Part III" for any additional information. This section may include details about your coverage and any exemptions.
  8. Review the entire form for accuracy. Double-check names, numbers, and premium amounts to ensure everything is correct.
  9. Once confirmed, keep a copy of the completed form for your records. You will need it when filing your tax return.

With the form filled out, you can now proceed to incorporate this information into your tax return. Make sure to file your taxes on time to avoid any penalties.

Misconceptions

The IRS 1095-A form is a crucial document for individuals who have health insurance coverage through the Health Insurance Marketplace. However, several misconceptions surround this form. Here are eight common misunderstandings:

  1. The 1095-A is only for people who received premium tax credits. Many believe that this form is only necessary for those who received financial assistance. In reality, anyone who enrolled in a Marketplace plan will receive a 1095-A, regardless of whether they received premium tax credits.
  2. The 1095-A is the same as a W-2. Some individuals confuse the 1095-A with the W-2 form, which reports wages. While both forms provide important tax information, the 1095-A specifically details health insurance coverage, not income.
  3. You don’t need the 1095-A if you didn’t use the Marketplace. If someone obtained health insurance through their employer or another source, they might think they do not need the 1095-A. However, if they had any Marketplace coverage at any point during the year, they still need this form for their tax return.
  4. The 1095-A is only for tax filing purposes. While it is essential for filing taxes, the 1095-A also serves as proof of health coverage, which can be important for various health-related applications or inquiries.
  5. The information on the 1095-A is always accurate. Some individuals assume that the information provided on the form is flawless. However, errors can occur. It is important to review the form carefully and report any discrepancies to the Marketplace.
  6. Receiving a 1095-A guarantees that you will not owe any taxes. Many mistakenly believe that having a 1095-A means they are exempt from owing taxes. However, tax liability depends on various factors, including total income and other tax credits.
  7. You can ignore the 1095-A if you didn’t have health issues. Some people think that if they did not use their insurance for medical care, they can disregard the 1095-A. This is incorrect; the form must be included when filing taxes, regardless of usage.
  8. The 1095-A only needs to be filed if you owe taxes. Many think they only need to worry about the 1095-A if they have a tax bill. In fact, this form is required for all taxpayers who had Marketplace coverage, regardless of whether they owe taxes or expect a refund.

Understanding these misconceptions can help individuals navigate their tax responsibilities more effectively and ensure compliance with IRS requirements.

Documents used along the form

The IRS 1095-A form is an important document for those who have health insurance through the Health Insurance Marketplace. It provides essential information that helps you fill out your tax return. Along with the 1095-A, there are several other forms and documents you may need to consider. Here’s a list of related forms that can assist you in the tax filing process.

  • IRS Form 1040: This is the standard individual income tax return form. You'll report your income, claim deductions, and calculate your tax liability using this form.
  • IRS Form 8962: This form is used to calculate the Premium Tax Credit. If you received a subsidy for your health insurance, you’ll need to complete this form to claim the credit on your tax return.
  • IRS Form 1095-B: This form shows whether you had minimum essential coverage during the year. It’s issued by insurance providers and is helpful for proving you met the health coverage requirement.
  • IRS Form 1095-C: If you work for a large employer, this form may be provided to you. It details the health coverage offered to you and your family by your employer.
  • IRS Form 8965: This form is used to claim an exemption from the Affordable Care Act's individual mandate. If you didn't have health insurance, you might need this form to avoid a penalty.
  • Minnesota Trailer Bill of Sale form: This legal document verifies the sale and transfer of ownership of a trailer, ensuring the transaction is recorded officially. For those looking to finalize the sale of a trailer, you're encouraged to view and download the document.
  • State Tax Forms: Depending on your state, you may need additional forms for state income tax. Each state has its own requirements, so check what applies to you.

Having these documents ready can simplify the tax filing process. Make sure to review each one carefully to ensure you have everything you need. This will help you avoid delays and make your tax experience smoother.