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Form 8963 Utasítások

8963. formanyomtatvány, egészségbiztosítási szolgáltató információinak jelentése

Rev. január 2020

Kapcsolódó űrlapok

  • Form 8963 - Egészségbiztosítási Szolgáltatói Információ
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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  
Note. See IRS.gov/ACA9010 for  
IRS e-file is the IRS’s electronic filing  
program. For more information about IRS  
e-file, go to IRS.gov/Form8963efile. By  
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  
services you may use, go to IRS.gov/PDS.  
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.  
See IRS.gov/ACA9010 for the  
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  
(see (i) Net premiums written, earlier). If  
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  
from IRS.gov/FormComments. Or you can  
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-