Formulaire 8963 Instructions
Instructions pour le formulaire 8963, Rapport des renseignements sur les fournisseurs d'assurance-maladie
Rev. Janvier 2020
Formulaires associés
- Formulaire 8963 - Rapport des renseignements sur les fournisseurs d'assurance-maladie
Department of the Treasury
Internal Revenue Service
Instructions for Form 8963
Report of Health Insurance Provider Information
(Rev. January 2020)
Section references are to the Internal Revenue
Code unless otherwise noted.
Note. If filing electronically, upload the
completed fillable version of the form. Do
not print and scan the form.
pursuant to ACA section 9010, as
amended. All information on this form is
subject to public disclosure. Do not
include personal information other than
that requested by this form.
Future Developments
If you’re not required to file
electronically, you may file a paper Form
8963.
For the latest information about
developments related to Form 8963 and
its instructions, such as legislation
enacted after they were published, go to
Definitions
Covered entity. Generally, covered
entity means any entity with net premiums
written for health insurance for U.S. health
risks during the fee year that is:
E-File: It’s Convenient, Safe,
and Secure
IRS e-file is the IRS’s electronic filing
program. For more information about IRS
filing electronically, you will receive an
electronic acknowledgment once you
complete the transaction. Keep it with your
records.
additional guidance.
A health insurance issuer within the
•
meaning of section 9832(b)(2);
A health maintenance organization
What’s New
•
within the meaning of section 9832(b)(3);
Forms 8963 reporting more than $25
million in net premiums written must be
filed electronically. See 26 C.F.R. section
57.3(a)(2)(ii), as amended by T.D. 9881,
for further details. For more information on
electronic filing, see How To File below.
An insurance company that is subject to
•
tax under subchapter L, Part I or II, or that
would be subject to tax under subchapter
L, Part I or II, but for the entity being
Where To File
exempt from tax under section 501(a);
If you are not required to file
electronically and prefer to file by
mail, send your paper Form 8963
to the following address.
An insurer that provides health
•
insurance under Medicare Advantage,
Medicare Part D, or Medicaid; or
General Instructions
Purpose of Form
A non-fully insured multiple employer
•
Internal Revenue Service
1973 Rulon White Blvd.
Mail Stop 4916 IPF
welfare arrangement (MEWA).
File Form 8963 during each fee year (year
the annual health insurance provider fee is
due) to report net premiums written for
U.S. health risks during the data year
(calendar year immediately preceding the
fee year). The IRS will use that information
when figuring the annual fee imposed by
Affordable Care Act (ACA) section 9010.
(Public Law (P.L.) 111-148, section 9010;
P.L. 111-148, section 10905; P.L.
Net premiums written. Net premiums
written means premiums written, including
reinsurance premiums written, reduced by
reinsurance ceded, and reduced by
ceding commissions and medical loss
ratio (MLR) rebates with respect to the
data year. Net premiums written includes
premiums written for assumption
Ogden, UT 84201-0051
Send the forms in a flat mailing envelope
(not folded). Do not staple, tear, or tape
any of these forms. If you are sending a
large number of forms in conveniently
sized packages, write your name on each
package and number the packages
consecutively.
reinsurance and is reduced by assumption
reinsurance premiums ceded. Net
premiums written does not include
premiums written for indemnity
111-152, section 1406; and P.L. 113-235,
division M.)
Who Must File
reinsurance and is not reduced by
indemnity reinsurance ceded.
U.S. postal regulations require forms
and packages to be sent by First-Class
Mail. However, you may use private
delivery services. To determine which
Generally, a covered entity that provides
health insurance for any U.S. health risk
during the 2020 fee year (the calendar
year in which the fee must be paid) must
file Form 8963.
Assumption reinsurance is
•
reinsurance for which there is a novation
and the reinsurer takes over the entire risk
of loss pursuant to a new contract.
If you mail your form, also fax it to
Indemnity reinsurance is an
•
When To File
877-797-0235.
TIP
agreement between one or more
You must file Form 8963 by April 15, 2020.
reinsuring companies and a covered entity
under which (a) the reinsuring company
agrees to accept, and to indemnify the
issuing company for, all or part of the risk
of loss under policies specified in the
agreement; and (b) the covered entity
retains its liability to, and its contractual
relationship with, the individuals whose
health risks are insured under the policies
specified in the agreement.
If you would like to request an
How To File
acknowledgment that we received your
Form 8963, please email LBI.IPF@irs.gov
with the company information and/or
tracking number and we will reply when
we receive the form. If you use an
If you have more than $25 million in net
premiums written to report, you must file
Form 8963 (including any corrected Forms
8963) electronically. If you are required to
file electronically, your Form 8963 will not
be considered filed unless it is filed
electronically.
overnight service, add the email address
LBI.IPF@irs.gov in the recipient email and
we will reply when we receive the form.
Public Disclosure
You can file Form 8963 (with Form
8453-R, Electronic Filing Declaration for
Form 8963) electronically by accessing
IRS e-file using your own computer, or, for
this year and Form 8963 only, you can fax
the Form 8963 to 877-797-0235.
In determining net premiums
written, filers must take
TIP
The information on this form is not
assumption reinsurance into
confidential. Although, generally, returns
and return information are confidential, as
required by section 6103, the information
on this form is not subject to section 6103,
account by including assumption
reinsurance written in direct premiums
written and deducting assumption
Jan 17, 2020
Cat. No. 60499R
reinsurance ceded from direct premiums
written. However, filers may not include
indemnity reinsurance written in direct
premiums written and may not deduct
indemnity reinsurance ceded from direct
premiums written.
below). Also complete the first line of
Schedule A.
Number of controlled group members
included in Schedule A. Enter the
number of controlled group members who
are listed on Schedule A, including the
entity in box 2a or 2b. If reporting as a
single-person covered entity, enter “1” for
the number of controlled group members.
Designated entity. Each controlled
group must have a designated entity.
If the controlled group, without regard
to foreign corporations included under
ACA section 9010(c)(3)(B), is also an
affiliated group that files a consolidated
U.S. health risk. A U.S. health risk
means the health risk of any individual
who is:
Entity name. If you checked box 1, enter
return for federal income tax purposes, the the name of the single-person covered
designated entity is the agent of the
affiliated group as identified on the tax
return filed for the data year.
entity in the entity name box. If you
checked box 2a or 2b, enter the name of
the designated entity. If you have a trade
name or are doing business under a
different name, enter that name or d/b/a
name on the “Entity name (continued)”
line.
A U.S. citizen,
•
A resident of the United States (within
•
the meaning of section 7701(b)(1)(A)), or
Located in the United States, with
•
If not, the controlled group must select
one of its members to be the designated
entity.
If a controlled group does not select a
designated entity, the IRS will select a
member of the controlled group as the
designated entity for the controlled group.
respect to the period that individual is so
located.
Health insurance. In general, the term
“health insurance” has the same meaning
as the term “health insurance coverage” in
section 9832(b)(1)(A), defined to mean
benefits consisting of medical care
(provided directly, through insurance or
reimbursement, or otherwise) under any
hospital or medical service policy or
certificate, hospital or medical service plan
contract, or health maintenance
Address. Enter a street address where
you can receive overnight deliveries.
Do not provide a P.O. box.
The designated entity is responsible for
!
the following for the group:
CAUTION
Filing Form 8963,
•
•
Third party. If you receive your mail in
care of a third party (such as an
Receiving IRS communications about
the fee,
accountant or an attorney), enter on the
first street address line “C/O” followed by
the third party's name and enter the street
address where the third party can receive
overnight deliveries on the “Address
(continued)” line.
Filing any necessary error correction
•
organization contract offered by a covered
entity.
report,
Paying the fee to the IRS,
•
•
Obtaining consents from all controlled
The term “health insurance”
group members that are required to be
listed on Schedule A of this form, and
includes limited scope (also called
stand-alone) dental and vision
TIP
Providing (to the IRS upon request) the
•
benefits under section 9832(c)(2)(A) and
retiree-only health insurance, but does not
include any other excepted benefits under
section 9832(c).
Foreign address. If reporting a
foreign address, include the full name of
the country using uppercase letters in
English. If you file Form 8963
consents obtained from controlled group
members that are required to be listed on
Schedule A of this form.
If the IRS selects the designated entity,
then all members of the controlled group
that are required to be listed on
electronically, select the full name of the
country from the drop down in the foreign
country name box. Enter foreign province
or state, and postal code.
For the definitions of controlled group,
single-person covered entity, and
designated entity, see Specific
Instructions, next.
Schedule A of this form will be deemed to
have consented to this election.
Part I. Signature of Official
Signing on Behalf of the
Single-Person Covered Entity
or Designated Entity (Agent of
an Affiliated Group, or Other
Designated Entity) and Consent
by the Designated Entity (if
applicable)
Box 2a. Agent of an affiliated group.
Check box 2a if you are the agent of an
affiliated group. You must also sign Part I
on page 1 (see Part I signature
Specific Instructions
Covered entity information. A covered
entity is either a single-person covered
entity or a member of a controlled group. A
single-person covered entity is a covered
entity that is not a member of a controlled
group. Under the controlled group rule of
ACA section 9010(c)(3), all persons
treated as a single employer under
sections 52(a), 52(b), 414(m), or 414(o)
will be treated as one covered entity. In
applying the single employer rules, ACA
section 9010(c)(3)(B) provides that a
foreign entity subject to tax under section
881 is included within a controlled group
under section 52(a) or 52(b). A person is
treated as being a member of a controlled
group if it is a member of the group at the
end of the day on December 31, 2019,
and would qualify as a covered entity in
2020 if it were a single-person covered
entity.
instructions below). Also complete the first
line of Schedule A, with your National
Association of Insurance Commissioners
(NAIC) company and group code and net
premiums written, if any.
Provide the date signed in MM/DD/YYYY
format, your phone and fax numbers, and
the name and title of your signing official in
print format.
Box 2b. Other. Check box 2b if you are
the designated entity for a covered entity
that is not an affiliated group. You must
also sign Part I on page 1 (see Part I
signature instructions below). Also
complete the first line of Schedule A, with
your NAIC company and group code and
net premiums written, if any.
If you file Form 8963 by paper,
manually sign the form.
If you file Form 8963 electronically, do
not manually sign the form. Instead,
manually sign, scan, and upload Form
8453-R with your Form 8963. See How To
File, earlier.
Corrected report. Check the box if this is
a corrected report.
Employer identification number (EIN).
Enter your EIN. If you do not have an EIN,
you must apply for one. If filing your Form
8963 electronically, enter your 9-digit EIN
without the dash. The EIN will be properly
formatted for you.
Part II. Alternate Contact
Person Designee
Box 1. Single-person covered entity.
Check box 1 if you are a single-person
covered entity. You must sign Part I on
page 1 (see Part l signature instructions
If you want to designate an employee to
discuss the report with the IRS, check the
related box and enter the person’s name,
title, phone number, and fax number, and
Instructions for Form 8963 (Rev. 01-2020)
-2-
we will contact that person if we have any
questions concerning the report.
written for health insurance of U.S. health
risks and any other information required
by this form.
1. Rebates paid
2. Less estimated rebates
unpaid-prior year
3. Plus estimated rebates
unpaid-current year
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
$ ________
$ (_______)
$ _______
Schedule A. Single-Person
Covered Entity or Controlled
Group Member Information
.
.
.
.
Generally, if the entity files an SHCE
and/or an MLR form, enter the direct
premiums written as reported for the data
year on the SHCE (SHCE, Part 2, line 1.1,
columns 1–10 plus 12) and/or MLR (MLR
form, Part 2, comparable lines and
.
.
.
4. MLR rebates (current year
Enter the single-person covered entity,
common parent of affiliated group, or
designated entity information on the first
line. This information will automatically
populate the first line of Schedule A if you
complete the form electronically. It is
unnecessary to repeat the entity name
and address from page 1 on line 1, but
you must enter all of the premium data
requested for the entity. Complete
additional lines for every person who is a
controlled group member at the end of the
day on December 31, 2019, and who
would qualify as a covered entity in 2020 if
it were a single-person covered entity, and
enter the following information for each
member.
accrual). Enter this net amount in
column (g). Place a minus sign in
front of amounts to indicate
columns, amounts from the “Total as of
12/31/Data Year” columns only).
negative amounts.
.
.
.
.
.
.
.
$ _______
References to the SHCE and the
MLR form in these instructions are
!
(h) Stand-alone dental or vision direct
premiums written. Enter the amount of
stand-alone dental or vision direct
premiums written as reported to the NAIC
on the SHCE. If you do not file an SHCE,
include direct premiums written for
policies providing for dental only or vision
only coverage issued as a stand-alone
dental or vision policy, or as a rider to a
medical policy through deductibles or
out-of-pocket limits.
CAUTION
solely for your convenience in
identifying the premium information
required for this report and are subject to
change.
Only include direct premiums written
for health insurance of U.S. health risks.
Exclude from direct premiums written any
premiums for coverage that is not health
insurance for U.S. health risks. For more
information, see the definitions of Health
(a) Employer identification number
(EIN). If filing your Form 8963
electronically, enter your 9-digit EIN
without the dash. The EIN will be properly
formatted for you.
(i) Net premiums written. Enter the total
of column (f) minus column (g) plus
column (h) in column (i).
For any covered entity that files the
SHCE with the NAIC, the entire amount
reported on the SHCE as direct premiums
written will be considered to be for health
insurance of U.S. health risks (subject to
any applicable exclusions for amounts that
are not health insurance) unless the
(b) Entity name. If you have a trade
name or are doing business under a
different name, enter that name or d/b/a
name.
(f) − (g) + (h) = (i)
This is 100% of the amount of net
premiums written for health insurance of
U.S. health risks for the calendar year.
The IRS will compute net premiums
written taken into account (in accordance
with Regulations section 57.4(a)(4)). If
negative, enter “-0-”. Any negative
amounts will be treated as zero for fee
calculation purposes.
covered entity can demonstrate otherwise.
(c) Address. Enter a street address
where you can receive overnight
deliveries.
If reporting a foreign address, also
include the full name of the country using
uppercase letters in English. Enter the
information in the following order: city,
province or state, and postal code.
If the entity does not file an SHCE with
NAIC or an MLR form with CCIIO, or those
forms do not contain the relevant data for
determining all of the direct premiums
written for health insurance for U.S. health
risks of an entity (or member), enter
comparable direct premiums written
information from any equivalent form
required by state or federal law.
If no single form contains all of the
relevant data for determining all of the
direct premiums written for health
insurance for U.S. health risks of an entity
(or member), then direct premiums written
must be determined using aggregated
data from multiple forms. Please include a
reconciliation with the premiums you
reported on the SHCE, MLR form, or
equivalent form required by state or
federal law.
(j) Amount in column (i) attributable to
section 501(c)(3), 501(c)(4), 501(c)
(26), or 501(c)(29) entities. All
(d) and (e) National Association of In-
surance Commissioners (NAIC) identi-
fication codes. Enter (d) NAIC company
code and (e) NAIC group code for each
single-person covered entity, the common
parent of an affiliated group or designated
entity, and each listed controlled group
member. If you do not have an NAIC
company code or group code for a
designated entities or controlled group
members who enter an amount in box j
must be organized as a tax-exempt entity
under section 501(c)(3), 501(c)(4), 501(c)
(26), or 501(c)(29).
Box 1 (or drop down menu). Enter
the section 501(c) paragraph number for
each entity that qualifies for the partial
exclusion, if applicable. Allowable
covered entity or controlled group
member, leave the related field blank.
(f) Direct premiums written. For each
single-person covered entity or member of
a controlled group, the source of data for
determining direct premiums written is the
Supplemental Health Care Exhibit
selections are 3, 4, 26, or 29. The entity
must be one of these types of entities in
order for it to qualify. If you file Form 8963
electronically, select the number of the
paragraph from the drop down box.
treatment of expatriate health plans.
(g) MLR rebates. Enter MLR rebates as
you reported for the 2019 calendar year
to: NAIC on SHCE; CCIIO on the MLR
form; or any other regulatory authority that
specifically requires MLR rebates for other
than commercial markets (Medicare Part
D, Medicare Advantage, Medicaid,
FEHBP, etc.).
(SHCE), filed with the NAIC; the Medical
Loss Ratio (MLR) Annual Reporting Form
(MLR form), filed with the Center for
Box 2. Enter the portion of net
premiums written included in the total
reported in column (i) for health insurance
premiums that are attributable to certain
exempt activities of a covered entity
qualifying under section 501(c)(3), 501(c)
(4), 501(c)(26), or 501(c)(29) (ACA
section 9010(b)(2)(B), partial exclusion for
certain exempt activities).
Consumer Information and Insurance
Oversight (CCIIO); or any equivalent form
required by state or federal law. If the
entity or member does not file an SHCE,
an MLR form, or any equivalent form, the
entity or member is still required to file
Form 8963 and provide direct premiums
Figure the MLR rebates (current year
accrual), as below.
Instructions for Form 8963 (Rev. 01-2020)
-3-
Enter 100% of the premiums that
qualify for the exclusion and the IRS will
apply the 50% reduction after application
of the percentage of net premiums written
the amount entered is greater than the net
premiums written reported in column (i), it
will be limited to the amount of column (i)
for that controlled group member for fee
calculation purposes.
contact the IRS by phone at 616-365-4617 on this form is subject to public disclosure.
(not a toll-free number), by fax at
877-797-0235, or by email at
Do not include personal information other
than that required to be disclosed.
The time needed to complete and file
this form will vary depending on individual
circumstances. The estimated average
time is:
Disclosure and Paperwork Reduction
Act Notice. We ask for the information on
this form to carry out the Internal Revenue
laws of the United States. You are
required to give us the information. We
need it to ensure that you are complying
with these laws and to allow us to figure
and collect the right fee.
Recordkeeping. . . . . . 5 hr., 30 min.
Error Correction Process
Learning about the
law or the form. . . . . .
Each fee year, the IRS will send a
preliminary fee notification to each
covered entity. If the entity believes there
is an error in the notification, the entity
must submit a corrected Form 8963 in the
time and manner specified in the
notification.
53 min.
Preparing the form . . 1 hr., 01 min.
You are not required to provide the
information requested on a form that is
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law.
Public disclosure, open to public
inspection. Although, generally, returns
and return information are confidential, as
required by section 6103, the information
on this form is not confidential and is not
subject to section 6103 pursuant to ACA
section 9010, as amended. All information
Comments. If you have comments
concerning the accuracy of these time
estimates or suggestions for making this
form simpler, we would be happy to hear
from you. You can send us comments
write to the Internal Revenue Service, Tax
Forms and Publications Division, 1111
Constitution Ave. NW, IR-6526,
Note. If you submit a corrected Form
8963 by e-file, you should receive an
electronic acknowledgement when you
complete the transaction. If you use
another method specified in the
notification, the IRS will mail an
acknowledgement to the address
indicated on the corrected Form 8963. If
you do not receive an acknowledgement
within 10 days of submission, please
Washington, DC 20224. Don’t send the
form to this office.
Instructions for Form 8963 (Rev. 01-2020)
-4-