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النموذج 8885 التعليمات

Instructions for Form 8885, Health Coverage Tax Credit

Rev. 2021

النماذج ذات الصلة

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Department of the Treasury  
Internal Revenue Service  
2021  
Instructions for Form 8885  
Health Coverage Tax Credit  
Section references are to the Internal Revenue  
Code unless otherwise noted.  
Any amounts you included on Form  
for those coverage months. Your election  
applies to your April through October  
coverage months.  
8885, line 4, or on Form 14095, The  
Health Coverage Tax Credit (HCTC)  
Reimbursement Request Form;  
What’s New  
Even if you can’t claim the HCTC  
Any qualified health insurance  
Expiration of the Health Coverage Tax  
Credit (HCTC). The HCTC expires at the  
end of 2021. The HCTC can't be claimed  
for coverage months beginning in 2022.  
The advance monthly payment program  
will continue through December 2021 but  
will not accept HCTC payments in 2022.  
on your income tax return, you  
!
coverage premiums you paid to “US  
Treasury-HCTC” for eligible coverage  
months for which you received the benefit  
of the advance monthly payment program;  
or  
CAUTION  
must still file Form 8885 to elect  
the HCTC for any months you participated  
in the advance monthly payment program.  
Failing to make a timely election will  
require you to report advance monthly  
HCTC payment amounts as an additional  
tax owed on your tax return.  
Any advance monthly payments your  
health plan administrator received from  
the IRS, as shown on Form 1099-H,  
Health Coverage Tax Credit (HCTC)  
Advance Payments.  
COBRA premium reductions. The  
American Rescue Plan Act of 2021  
provided temporary 100% premium  
subsidies for eligible former employees  
enrolled in COBRA coverage. If you  
received a 100% COBRA premium  
reduction from your former employer or  
COBRA administrator, don’t check any  
boxes on line 1 for the coverage months  
for which you received such reduction.  
You aren’t eligible to claim the HCTC for  
those months and may need to repay on  
line 5 any advance payments of the HCTC  
made for your benefit for those months.  
Definitions and Special  
Rules  
Who Can Take This Credit  
TAA Recipient  
You can elect to take the HCTC only if (a)  
you were an eligible TAA, ATAA, or RTAA  
recipient or PBGC payee in 2021; or you  
were the qualifying family member of an  
eligible TAA, ATAA, or RTAA recipient or  
PBGC payee who passed away or  
You were an eligible TAA recipient as of  
the first day of the month if, for any day in  
that month or the prior month, you:  
Received a trade readjustment  
allowance, or  
finalized a divorce with you (see  
Would have been entitled to receive  
such an allowance except that you hadn’t  
exhausted all rights to any unemployment  
insurance (except additional  
(b) you can’t be claimed as a dependent  
on someone else’s 2021 tax return; and  
(c) you met all of the other conditions  
listed on line 1. If you can’t be claimed as  
a dependent on someone else’s 2021 tax  
return, review Form 8885, Part I, to see if  
you are eligible to take this credit.  
Future Developments  
compensation that is funded by a state  
and isn’t reimbursed from any federal  
funds) to which you were entitled (or  
would be entitled if you applied).  
For the latest information about  
developments related to Form 8885 and  
its instructions, such as legislation  
enacted after they were published, go to  
Example. You received a trade  
readjustment allowance for January 2021.  
You were an eligible TAA recipient as of  
the first day of January and February.  
Relatively few people are eligible  
Election to take the HCTC. You must  
elect the HCTC to receive the benefit of  
the HCTC. Make your election by  
for the HCTC. See Who Can Take  
!
CAUTION  
This Credit, later, to determine  
ATAA Recipient  
whether you can claim the credit.  
checking the box on line 1 for the first  
eligible coverage month you are electing  
to take the HCTC and all boxes on line 1  
for each eligible coverage month after the  
election month. Once you elect to take the  
HCTC for a month in 2021, the election to  
take the HCTC applies to all subsequent  
eligible coverage months in 2021. The  
election doesn’t apply to any month for  
which you aren’t eligible to take the HCTC.  
You were an eligible ATAA recipient as of  
the first day of the month if, for that month  
or the prior month, you received benefits  
under an alternative trade adjustment  
assistance program for older workers  
established by the Department of Labor.  
General Instructions  
Purpose of Form  
Use Form 8885 to elect and figure the  
amount, if any, of your HCTC.  
Example. You received benefits under  
an alternative trade adjustment assistance  
program for older workers for October  
2021. The program was established by  
the Department of Labor. You were an  
eligible ATAA recipient as of the first day  
of October and November.  
Self-Employed Health Insurance De-  
duction Worksheet. If you are  
For 2021, the election must be made  
no later than the due date (including  
extensions) of your tax return.  
completing the Self-Employed Health  
Insurance Deduction Worksheet in your  
tax return instructions and you were an  
eligible trade adjustment assistance (TAA)  
recipient, alternative TAA (ATAA)  
recipient, reemployment TAA (RTAA)  
recipient, or Pension Benefit Guaranty  
Corporation (PBGC) payee, you must  
complete Form 8885 before completing  
that worksheet. When figuring the amount  
to enter on line 1 of the worksheet, do not  
include:  
Example. You were an eligible RTAA  
recipient between February 2021 and  
October 2021 and you otherwise met the  
HCTC requirements during that period.  
You wish to take the HCTC starting in April  
2021. You would check the box on line 1  
for April to elect the HCTC for your April  
coverage. You must then check every box  
on line 1 through, and including, October  
because you’re eligible to take the HCTC  
RTAA Recipient  
You were an eligible RTAA recipient as of  
the first day of the month if, for that month  
or the prior month, you received benefits  
under a reemployment trade adjustment  
assistance program for older workers  
established by the Department of Labor.  
Dec 01, 2021  
Cat. No. 68158V  
 
Example. You received benefits under  
a reemployment trade adjustment  
described in section 9832(c). For  
example, if you purchase dental or vision  
benefits separately, these benefits aren’t  
qualified health insurance coverage. But, if  
you purchase dental or vision benefits as  
part of a comprehensive package and  
these benefits don’t represent  
Qualified Health Insurance  
Coverage  
assistance program for older workers for  
January 2021. The program was  
Qualified health insurance coverage for  
the HCTC is any of the following.  
established by the Department of Labor.  
You were an eligible RTAA recipient as of  
the first day of January and February.  
1. Coverage under a group health  
plan available through the employment of  
your spouse, but see the instructions for  
line 1, later, for information on when  
enrollment in, or an offer of,  
substantially all of its coverage, the  
comprehensive package of benefits,  
including the dental and vision benefits,  
may be qualified health insurance  
coverage and the premiums paid may be  
eligible for the HCTC.  
PBGC Payee  
You were an eligible PBGC payee as of  
the first day of the month if both of the  
following apply.  
employer-sponsored coverage makes you  
an individual ineligible for the HCTC.  
1. You were age 55 to 65 and not  
enrolled in Medicare as of the first day of  
the month.  
2. You received a benefit for that  
month that was paid by the PBGC under  
title IV of the Employee Retirement  
Income Security Act of 1974 (ERISA).  
2. Coverage under a non-group  
(individual) health insurance plan other  
than a qualified health plan offered  
through a Marketplace. Individual health  
insurance doesn’t include any insurance  
connected with a group health plan or  
federal- or state-based health insurance  
coverage.  
3. Coverage under a Consolidated  
Omnibus Budget Reconciliation Act  
(COBRA) continuation provision (as  
defined in section 9832(d)(1)).  
For more information about  
whether your coverage is qualified  
health insurance coverage, go to  
TIP  
Qualifying Family Member  
A qualifying family member is:  
If you received a lump-sum payment  
from the PBGC after August 5, 2002, you  
meet item (2) above for any month that  
you would have received a PBGC benefit  
if you hadn’t received the lump-sum  
payment.  
Your spouse (a spouse doesn’t include  
someone who is legally separated from his  
or her spouse under a decree of divorce or  
of separate maintenance (but see Married  
or  
4. State-based coverage. State-based  
coverage includes the following.  
Continued Qualification for  
Family Members After Certain  
Life Events  
Anyone whom you can claim as a  
a. Continuation coverage provided by  
the state under a state law that requires  
such coverage.  
b. A qualified state high-risk pool (as  
defined in section 2744(c)(2) of the Public  
Health Service Act).  
dependent (but see the exception for  
Parents, later).  
Qualifying family members (spouses and  
dependents) (see Qualifying Family  
Member, later) can be considered  
For any month that you are eligible to  
take the HCTC, you can include premiums  
paid for a qualifying family member for that  
eligible coverage month if all of the  
recipients and file Form 8885 under their  
name and social security number after  
certain life events. You are considered a  
recipient and are eligible to newly receive,  
or continue to receive, the HCTC in the  
event that a related TAA, ATAA, or RTAA  
recipient or PBGC payee dies or finalizes  
a divorce with you and you were a  
c. A health insurance program offered  
for state employees.  
following statements were true as of the  
first day of that eligible coverage month.  
d. A state-based health insurance  
program that is comparable to the health  
insurance program offered for state  
employees.  
e. An arrangement entered into by a  
state and (i) a group health plan (including  
such a plan that is a multiemployer plan as  
defined in section 3(37) of ERISA), (ii) an  
issuer of health insurance coverage, (iii)  
an administrator, or (iv) an employer.  
f. A state arrangement with a private  
sector health care coverage purchasing  
pool.  
g. A state-operated health plan that  
doesn’t receive any federal financial  
participation.  
The qualifying family member was  
covered by qualified health insurance  
coverage for which you paid some or all of  
the premiums. You and your qualifying  
family member don’t have to be covered  
by the same coverage.  
qualifying family member immediately  
before such event. The TAA, ATAA, or  
RTAA recipient or PBGC payee doesn’t  
need to elect the HCTC prior to the event.  
People who were qualifying family  
The qualifying family member wasn’t  
enrolled in Medicare Part A, B, or C.  
The qualifying family member wasn’t  
enrolled in Medicaid or the Children’s  
Health Insurance Program (CHIP).  
members can receive the tax credit for  
eligible coverage months up to 24 months  
from the death or divorce, or until the first  
coverage month that begins on or after  
January 1, 2022, whichever comes first.  
Eligibility to receive the HCTC may begin  
in either the month of the death or divorce  
or the month following the death or  
divorce.  
Example. Your spouse was a PBGC  
payee and died on August 20, 2020. You  
are eligible to receive the HCTC as a  
recipient for coverage for August 2020  
through December 2021, subject to the  
other general HCTC requirements. If you  
didn't have separate coverage for August,  
you are eligible to receive the HCTC as a  
recipient for coverage for September 2020  
through December 2021, subject to the  
other general HCTC requirements.  
The qualifying family member wasn’t  
enrolled in the Federal Employees Health  
Benefits Program (FEHBP) or eligible to  
receive benefits under the U.S. military  
health system (TRICARE).  
The qualifying family member wasn’t  
5. Coverage under a health plan  
covered by, or eligible for coverage under,  
any employer-sponsored health insurance  
coverage as described in the instructions  
for line 1, later.  
funded by a voluntary employees’  
beneficiary association (VEBA) that was  
established through a bankruptcy court.  
Exception. Qualified health insurance  
coverage doesn’t include any of the  
following.  
Note. If you are an eligible TAA, ATAA, or  
RTAA recipient or PBGC payee who  
enrolled in Medicare, you may be able to  
take the HCTC for coverage of qualifying  
family members. You can receive the  
HCTC for the health plan premiums of  
your qualifying family member(s) for  
eligible coverage months up to 24 months  
from the month you enrolled in Medicare,  
or until the first coverage month that  
begins on or after January 1, 2022,  
Any state-based coverage listed in  
items 4a through 4g above unless it also  
meets the requirements of section 35(e)  
(2).  
A flexible spending or similar  
arrangement.  
Any insurance if substantially all of its  
coverage is of excepted benefits  
Instructions for Form 8885 (2021)  
-2-  
     
whichever comes first. In order to receive  
resided with each parent for an equal  
different coverage. For example, if you  
elect the HCTC for self-only COBRA  
coverage in a month, you can take the  
PTC for the Marketplace coverage of your  
family members for that same month if you  
and your eligible family members are  
otherwise eligible to take the PTC and the  
HCTC, as applicable.  
the HCTC, your qualifying family members number of nights in 2021, the custodial  
must meet all of the requirements  
described earlier.  
parent is the parent with the higher  
adjusted gross income for 2021.  
The child’s other parent can claim the  
Married Persons Filing  
Separate Returns  
child as a dependent under the rules for  
children of divorced or separated parents.  
See the Instructions for Forms 1040 and  
1040-SR, or Pub. 501, Dependents,  
Standard Deduction, and Filing  
Your spouse isn’t treated as a qualifying  
family member if you and your spouse file  
separate returns and either (1) or (2)  
below applies.  
You may also be able to claim the  
HCTC and the PTC for different coverage  
of the same individuals in different months  
of the year but need to apply the following  
special instructions for completing Form  
8962. If you elected to take the HCTC or  
received the benefit of advance payments  
of the HCTC for at least 1 month of the  
year and the individual(s) covered under  
the qualified health insurance coverage for  
the HCTC were also enrolled in a qualified  
health plan offered through a Marketplace  
for at least 1 other month of the year,  
complete Form 8962 as provided in the  
Form 8962 instructions, but:  
Information, for details.  
1. Your spouse was also an eligible  
TAA, ATAA, or RTAA recipient or PBGC  
payee in 2021.  
Conversely, if you can claim your child  
as a dependent under the special rule for  
a child of divorced or separated parents  
but you aren’t the child’s custodial parent,  
the child isn’t your qualifying family  
2. All of the following apply.  
a. You lived apart from your spouse  
member for purposes of the HCTC.  
during the last 6 months of 2021.  
The child must also meet all the  
b. A qualifying family member (other  
than your spouse) lived in your home for  
more than half of 2021.  
other conditions of a qualifying  
!
CAUTION  
family member, defined earlier, in  
order for you to claim the HCTC for the  
qualified health insurance coverage of the  
child.  
c. You provided over half of the cost  
of keeping up your home.  
Figure your PTC for only those months  
Children of Divorced or  
Separated Parents  
not checked on Form 8885, line 1;  
Complete Form 8962, column (f) of  
Participants in a Health  
Insurance Marketplace  
lines 12 through 23, for all months for  
which advance payments of the premium  
tax credit (APTC) were made, even those  
months checked on Form 8885, line 1;  
and  
Even if you can’t claim your child as a  
dependent, he or she is treated as your  
qualifying family member for the HCTC if  
both of the following apply.  
A qualified health plan offered through a  
Marketplace isn’t qualified health  
insurance coverage for the HCTC in 2021.  
And you can’t take the premium tax credit  
(PTC) for any months checked on line 1.  
However, subject to the general eligibility  
and election rules for the HCTC and the  
PTC, you may be able to claim the PTC  
and the HCTC in the same month for  
You were the child’s custodial parent.  
If you complete Form 8962, line 27  
Generally, the custodial parent is the  
parent with whom the child resided for the  
greater number of nights in 2021. If the  
counting nights rule applies, and the child  
(Excess advance payment of PTC),  
determine Form 8962, line 28 (Repayment  
limitation), as follows.  
Instructions for Form 8885 (2021)  
-3-  
     
IF . . .  
THEN . . .  
the amount on Form 8962, line 5, is 400 or more,  
the amount on Form 8962, line 24, is zero or blank,  
leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.  
leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.  
you didn’t receive the benefit of advance monthly payments of the HCTC, leave Form 8962, line 28, blank and enter the amount from line 27 on line 29.  
the amount on Form 8962, line 24, is greater than zero,  
after you complete Form 8962, line 27, complete Form 8885.  
and  
If you aren’t instructed to complete the Excess Advance HCTC Repayment Worksheet  
for Form 8885, line 5, add the amount from Form 8885, line 5, if any, to the applicable  
repayment limitation provided in the instructions for Form 8962, line 28. Enter the result  
on Form 8962, line 28, and complete Form 8962, line 29.  
you received the benefit of advance monthly payments of the HCTC for  
at least 1 month of the year for individual(s) who were enrolled in a  
qualified health plan offered through a Marketplace for at least 1 other  
month of the year,  
If you are instructed to complete the Excess Advance HCTC Repayment Worksheet for  
Form 8885, line 5, complete only lines 1 and 2 of the worksheet and do one of the  
following.  
(1) If line 1 of the worksheet is greater than or equal to line 2 of the worksheet:  
(a) Complete line 3 of the worksheet and enter the amount on Form 8885, line 5,  
and Schedule 3 (Form 1040), 1040-SS, or 1040-PR, as instructed;  
(b) On Form 8962, line 28, enter the sum of the amount on Form 8885, line 5,  
and the applicable repayment limitation provided in the instructions for Form  
8962, line 28; and  
(c) Complete Form 8962, line 29.  
(2) If line 1 of the worksheet is less than line 2 of the worksheet:  
(a) Complete Form 8962, lines 28 and 29, using the applicable repayment  
limitation provided in the Instructions for Form 8962 without any  
adjustments; and  
(b) Using this information, complete lines 4 through 7 of the worksheet as  
instructed.  
a. You were eligible for qualified  
health insurance coverage (including any  
Line 2  
Specific Instructions  
Line 1  
If your qualified health insurance  
employer-sponsored health insurance  
plan of your spouse) (other than the  
coverage listed under item 3, 4a, or 4e in  
Coverage, earlier) where the employer  
would have paid 50% or more of the cost  
of the coverage.  
coverage covers anyone other  
than you and your qualifying  
!
CAUTION  
You must elect the HCTC to receive the  
benefit of the HCTC. Check the box for the  
first eligible coverage month you are  
electing to take the HCTC. All of the  
statements listed on the form, and as  
further explained in these instructions,  
must be true as of the first day of that  
month. You must also check the box for  
each month after the election month for  
which all of the statements listed on the  
form are true as of the first day of that  
month, even if you aren’t claiming the  
HCTC for those months.  
family members, see Pub. 502, Medical  
and Dental Expenses, before completing  
line 2 to determine which amounts are  
considered to be paid for coverage for you  
and your qualifying family members.  
b. You were covered under any  
qualified health insurance coverage  
(including any employer-sponsored health  
insurance plan of your spouse) (other than  
the coverage listed under item 3, 4a, or 4e  
in the definition of Qualified Health  
Insurance Coverage, earlier) and the  
employer paid any part of the cost of the  
coverage.  
Enter the total amount of insurance  
premiums paid by you for coverage for  
you and all qualifying family members  
Coverage, earlier, for all eligible coverage  
months checked on line 1. But don’t  
include any insurance premiums paid by  
you to “US Treasury-HCTC.” Also don’t  
include any advance monthly payments  
your health plan administrator received  
from the IRS, as shown on Form 1099-H,  
box 1, or any insurance premiums you  
paid for which you received a  
Employer-sponsored health insurance  
coverage. Don’t check the box for any  
month that, as of the first day of the month,  
either (1) or (2) applies.  
1. You were covered under any  
employer-sponsored health insurance  
plan (including any employer-sponsored  
health insurance plan of your spouse)  
(except insurance substantially all of the  
coverage of which is of excepted benefits  
described in section 9832(c)) and the  
employer paid 50% or more of the cost of  
the coverage.  
Any amounts contributed to the  
cost of coverage by you or your  
!
CAUTION  
spouse on a pre-tax basis are  
considered to have been paid by the  
employer.  
reimbursement of the HCTC during the  
year by filing Form 14095.  
Example. You had health insurance  
coverage under an employer-sponsored  
health insurance plan as of October 1. The  
employer paid 40% of the cost of the  
coverage. You paid 60% of the cost of the  
coverage through pre-tax contributions.  
You can’t take the HCTC for the month of  
October because the employer is  
Example 1. You checked January on  
line 1. You paid $225 ($200 for basic  
coverage and $25 for dental benefits  
which are purchased separately) directly  
to your health plan for your January  
coverage. The $25 you paid for dental  
benefits is ineligible for the HCTC. You  
would include the $200 you paid for your  
basic insurance on line 2.  
2. You were an eligible ATAA or  
RTAA recipient and either of the following  
applies.  
considered to have paid 100% of the cost  
of the coverage.  
Instructions for Form 8885 (2021)  
-4-  
 
Excess Advance HCTC Repayment Worksheet—Line 5  
1. Multiply the amount from Form 8885, line 4, by 72.5% (0.725)  
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1.  
2.  
2. Enter the total advance monthly payments of the HCTC made on your behalf for coverage for any month not checked on Form 8885, line 1 (see  
Form 1099-H) and reimbursements of the HCTC you received by filing Form 14095 for any month not checked on Form 8885, line 1. If line 2 is  
greater than line 1, skip line 3 and go to line 4  
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3. Subtract line 2 from line 1. Enter the result here and on:  
Form 8885, line 5; and  
Schedule 3 (Form 1040), line 13c; Form 1040-SS, line 10; or Form 1040-PR, line 10.  
Don’t complete the rest of this worksheet  
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3.  
4.  
4. Subtract line 1 from line 2. Enter the result here  
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5. Consider all the individual(s) covered under the health insurance coverage for which you received the benefit of the advance monthly payments  
of the HCTC during the year. Were any of those individual(s) also enrolled in a qualified health plan offered through a Marketplace for at least 1  
other month of the year?  
Yes. Complete Form 8962 using the special instructions under Participants in a Health Insurance Marketplace, earlier. Go to line 6.  
No. Skip line 6. Enter the amount from line 4 on line 7.  
6. Is the amount on Form 8962, line 5, less than 400 AND the amount on Form 8962, line 24, greater than zero?  
Yes.  
IF . . .  
THEN enter on line 6 . . .  
Form 8962, line 28, is blank,  
the sum of Form 8962, line 26, and the  
applicable repayment limitation provided in the  
instructions for Form 8962, line 28.  
Form 8962, line 28, isn’t blank,  
Form 8962, line 28, reduced by Form 8962,  
line 29.  
Note. If you are married filing jointly and both you and your spouse must file Forms 8885, one spouse should  
figure their repayment limitation on line 6 of this worksheet. If line 6 is greater than line 7, enter the difference  
on line 6 of the second spouse’s worksheet. Otherwise, enter zero on lines 6 and 7 of the second spouse’s  
worksheet.  
No. Leave line 6 blank. Enter the amount from line 4 on line 7.  
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6.  
7. If you entered an amount on line 6, enter the smaller of line 4 or line 6 here. Also enter the items below where indicated.  
IF you’re filing . . .  
THEN include the amount on  
line 7 in the total entered on . . .  
AND enter “HCTC” and the amount on line 7 . . .  
in the space next to box 3 on line 16; then check box 3.  
on the dotted line next to line 6.  
Form 1040, 1040-SR, or  
1040-NR,  
line 16  
Form 1040-SS or 1040-PR,  
line 6  
Then, on Form 8885, line 5, enter the line 7 amount as a negative number by enclosing it in parentheses.  
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7.  
Example 2. You checked December  
on line 1. You participated in the advance  
monthly payment program and paid only  
$88 (27.5%) of your $320 December  
premium to “US Treasury-HCTC.” You  
received a Form 1099-H showing an  
advance payment of $232 (72.5% of the  
$320 premium) for your December  
received the benefit of an advance  
Line 5  
monthly payment for any month not  
If the resulting amount from line 5 is  
negative, zero, or blank, you can’t claim  
the HCTC on your income tax return.  
However, you must still file Form 8885 to  
elect the HCTC for any months you  
participated in the advance monthly  
payment program.  
checked on line 1 (see Form 1099-H) or  
received a reimbursement of the HCTC  
during the year by filing Form 14095 for  
any month not checked on line 1. You  
must reduce the amount on line 5 by the  
total of these payments. Use the Excess  
figure the amount of the excess advance  
monthly payment that you must repay.  
coverage. You wouldn’t include any part of  
the December coverage premium on line 2  
because you already received the benefit  
of the advance monthly payment program  
for December. You must still file Form  
8885 to elect the HCTC for December.  
You received an excess advance  
monthly payment of the HCTC if you  
Instructions for Form 8885 (2021)  
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count towards the HCTC, such as dental  
or vision coverage or coverage for family  
cost of the coverage (TAA recipients and  
PBGC payees) or made no contributions  
Required Documents  
If you claim any HCTC on line 5, you must  
provide verifiable proof for each month  
you are claiming the credit on line 2 that  
your health insurance coverage is  
members who aren’t eligible for the HCTC, to the cost of coverage (ATAA and RTAA  
your documentation must also specify  
those ineligible amounts.  
3. Proof of payment for each month  
you are claiming the credit on line 2, such  
as:**  
recipients).  
E-filed return. If you e-file, you can  
qualified health insurance coverage for the  
HCTC and that you paid premiums for the  
qualified health insurance coverage by  
attaching the documents listed below to  
your Form 8885. No documents are  
attach a copy of any required documents  
to an electronically filed return as a PDF if  
your tax software supports it, or you must  
a. Canceled checks (copy of front and attach those documents to Form 8453,  
back),  
U.S. Individual Income Tax Transmittal for  
an IRS e-file Return, and mail them to the  
IRS according to the instructions for that  
form.  
required if you file Form 8885 only to elect  
the HCTC for months you participated in  
the advance monthly payment program.  
b. Bank statements,  
c. Credit card statements, or  
d. Money orders.  
Example 1. You checked June and  
July on line 1. Your insurance coverage for  
each month costs $750 ($500 for you and  
$250 for your qualifying family members).  
You paid $750 directly to your health plan  
for your June coverage. You then paid  
$206.25 (27.5% of the $750 premium) for  
your July coverage as part of the advance  
monthly payment program. Your health  
plan administrator received an advance  
payment of $543.75 (72.5% of the $750  
premium) from the IRS for your July  
All health plans. For all health plans,  
you must include all of the following  
documents.  
1. An official letter reflecting that you  
were an eligible individual for the months  
claimed on line 2 in 2021.  
**Your proof of payment must indicate  
the amount paid and to whom it was paid.  
If you don’t have one of these types of  
proof of payment, contact your health plan  
for a record of your payment(s).  
For trade-certified individuals  
COBRA coverage. You must include  
the information under All health plans,  
earlier, and one of the following  
documents.  
1. A copy of your completed and  
signed COBRA Election Letter. It may also  
be called a COBRA Enrollment Form,  
Application Form, Enrollment Application  
for Continuing Coverage, or Election  
Agreement.  
demonstrating TAA, ATAA, or RTAA  
eligibility—A copy of the official letter from  
the Department of Labor, your state  
workforce agency, or employment office  
stating you are eligible for trade  
adjustment benefits.  
coverage. You received a Form 1099-H  
showing an advance payment of $543.75  
for your July coverage. You would include  
the $750 you paid for your June coverage  
on line 2. You wouldn’t include any part of  
the July coverage premium on line 2  
because you already received the benefit  
of the advance monthly payment program  
for July. You must attach copies of your  
health insurance bills and proof of  
For PBGC eligibility—A copy of the  
official letter or a copy of your 2021 Form  
1099-R, Distributions From Pensions,  
Annuities, Retirement or Profit-Sharing  
Plans, IRAs, Insurance Contracts, etc.,  
from the PBGC showing you received a  
benefit paid by the PBGC.  
2. A letter from your former employer  
or COBRA administrator saying you have  
COBRA coverage. The letter must have:  
a. The COBRA coverage start and  
2. A copy of your health insurance  
bills or COBRA payment coupons for each  
month you are claiming the credit on  
line 2.* The bills must have:  
end dates;  
payment for the June coverage for you  
and your qualifying family members  
b. Name of the health plan;  
c. Your home address; and  
d. Covered family members, their  
dates of birth, their relationship to you, and  
their social security numbers.  
totaling $750, along with any other  
a. Your name (or name of the policy  
required documents. You don’t need to  
attach documents for your July coverage.  
holder),  
b. The name of your health plan,  
c. Your monthly premium amount,  
d. Dates of coverage, and  
Example 2. You checked March and  
April on line 1. Your insurance coverage  
for each month costs $750 ($500 for you  
and $250 for your qualifying family  
members). You paid $750 directly to your  
health plan for each month. You would  
include $1,500 on line 2 for the March and  
April coverage. You must attach copies of  
your health insurance bills and proof of  
payment for the March and April coverage  
for you and your qualifying family  
3. A copy of “Notice of Rights to  
Continue Coverage.”  
e. Your health plan identification  
Coverage through your spouse’s  
employer. You must include the  
information under All health plans, earlier,  
and the following documents.  
number(s).  
*If your health plan doesn’t provide  
members with an insurance bill or COBRA  
payment coupon, you must provide health  
plan enrollment documents or an official  
letter from your health plan that has the  
required information listed under items 2a  
through 2e above. If your monthly  
Copies of paycheck stubs showing the  
health coverage deductions for each  
month you are claiming the credit on  
line 2.  
members totaling $1,500 ($750 for each  
month), along with any other required  
documents.  
A letter or other statement from your  
spouse’s employer that states the  
premium includes amounts that don’t  
employer contributed less than 50% of the  
Instructions for Form 8885 (2021)  
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