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Instrukcje dla formularzy 1094- C i 1095- C

Instrukcje dla formularzy 1094- C i 1095- C

Rev. 2023 r

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Department of the Treasury  
Internal Revenue Service  
2023  
Instructions for Forms  
1094-C and 1095-C  
Section references are to the Internal Revenue Code unless  
otherwise noted.  
report information about each employee to the IRS and to the  
employee. Forms 1094-C and 1095-C are used in determining  
whether an ALE Member owes a payment under the employer  
shared responsibility provisions under section 4980H. Form  
1095-C is also used in determining the eligibility of employees  
for the premium tax credit.  
Future Developments  
For the latest information about developments related to Form  
1094-C, Transmittal of Employer-Provided Health Insurance  
Offer and Coverage Information Returns, and Form 1095-C,  
Employer-Provided Health Insurance Offer and Coverage, and  
the instructions, such as legislation enacted after they were  
published, go to IRS.gov/Form1094C and IRS.gov/Form1095C.  
ALE Members that offer employer-sponsored, self-insured  
coverage also use Form 1095-C to report information to the IRS  
and to employees about individuals who have minimum essential  
coverage under the employer plan.  
What’s New  
Who Must File  
The electronic-filing threshold for information returns required to  
be filed on or after January 1, 2024, has been decreased to 10 or  
more returns. See Electronic Filing, later.  
An ALE Member must file one or more Forms 1094-C (including  
a Form 1094-C designated as the Authoritative Transmittal,  
whether or not filing multiple Forms 1094-C), and must file a  
Form 1095-C for each employee who was a full-time employee  
of the ALE Member for any month of the calendar year.  
Generally, the ALE Member is required to furnish a copy of the  
Form 1095-C (or a substitute form) to the employee.  
Additional Information  
For information related to the Affordable Care Act, visit IRS.gov/  
ACA. For the final regulations under section 6056, Information  
Reporting by Applicable Large Employers on Health Insurance  
Coverage Offered Under Employer-Sponsored Plans, see T.D.  
9661, 2014-13 I.R.B. 855, at IRS.gov/irb/2014-13_IRB/ar09.html.  
For the final regulations under section 6055, Information  
Reporting of Minimum Essential Coverage, see T.D. 9660,  
2014-13 I.R.B. 842, at IRS.gov/irb/2014-13_IRB/ar08.html and  
T.D. 9970, 2023-02 I.R.B. 311, at IRS.gov/irb/2023-02_IRB. For  
the final regulations under section 4980H, Shared Responsibility  
for Employers Regarding Health Coverage, see T.D. 9655,  
2014-9 I.R.B. 541, at IRS.gov/irb/2014-9_IRB/ar05.html. For  
answers to frequently asked questions regarding the employer  
shared responsibility provisions and related information reporting  
requirements, visit IRS.gov.  
An ALE Member is, generally, a single person or entity that is  
an Applicable Large Employer, or if applicable, each person or  
entity that is a member of an Aggregated ALE Group. An  
Applicable Large Employer, generally, is an employer with 50 or  
more full-time employees (including full-time equivalent  
employees) in the previous year. For purposes of determining if  
an employer or group of employers is an Applicable Large  
Employer, all ALE Members under common control (an  
Aggregated ALE Group) are aggregated together. If the  
Aggregated ALE Group, taking into account the employees of all  
ALE Members in the group, employed on average 50 or more  
full-time employees (including full-time equivalent employees) on  
business days during the preceding calendar year, then the  
Aggregated ALE Group is an Applicable Large Employer and  
each separate employer within the group is an ALE Member.  
Each ALE Member is required to file Forms 1094-C and 1095-C  
reporting offers of coverage to its full-time employees (even if the  
ALE Member has fewer than 50 full-time employees of its own).  
For information related to filing Forms 1094-C and 1095-C  
electronically, visit IRS.gov/AIR. For FAQs specifically related to  
completing Forms 1094-C and 1095-C, go to IRS.gov/  
For additional guidance and proposed regulatory changes  
relating to section 6055, including the requirement to solicit the  
TIN of each covered individual for purposes of the reporting of  
health coverage information, see Proposed Regulations section  
1.6055-1(h) and Regulations section 301.6724-1.  
For more information on which employers are subject to the  
employer shared responsibility provisions of section 4980H, see  
Employer in the Definitions section of these instructions. For  
more information on determining full-time employees, see  
Full-Time Employee in the Definitions section of these  
instructions, which includes information on the treatment of new  
hires and employees in Limited Non-Assessment Periods.  
General Instructions for  
For purposes of reporting on Forms 1094-C and 1095-C,  
an employee in a Limited Non-Assessment Period is not  
considered a full-time employee during that period.  
TIP  
Forms 1094-C and 1095-C  
See Definitions, later, for key terms used in these instructions.  
Purpose of Form  
Reporting by Employers That  
Employers with 50 or more full-time employees (including  
full-time equivalent employees) in the previous year use Forms  
1094-C and 1095-C to report the information required under  
sections 6055 and 6056 about offers of health coverage and  
enrollment in health coverage for their employees. Form 1094-C  
must be used to report to the IRS summary information for each  
Applicable Large Employer (ALE Member) (defined below) and  
to transmit Forms 1095-C to the IRS. Form 1095-C is used to  
Sponsor Self-Insured Health Plans  
An employer that offers health coverage through a self-insured  
health plan must report information about each individual  
enrolled in such coverage. For an employer that is an ALE  
Member, this information must be reported on Form 1095-C, Part  
III, for any employee who is enrolled in coverage (and any  
spouse or dependent of that employee). See the option to file  
Sep 26, 2023  
Cat. No. 63018M  
Form 1094-B and Form 1095-B, rather than Form 1094-C and  
Form 1095-C, to report coverage of certain non-employees,  
below.  
Substitute Statements to Recipients  
If you are not using the official IRS form to furnish statements to  
recipients, see Pub. 5223, General Rules and Specifications for  
Affordable Care Act Substitute Forms 1095-A, 1094-B, 1095-B,  
1094-C, and 1095-C, which explains the requirements for format  
and content of substitute statements to recipients. You may  
develop them yourself or buy them from a private printer.  
Substitute statements furnished to recipients may be in portrait  
format; however, substitute returns filed with the IRS using paper  
must be printed in landscape format.  
ALE Members that offer health coverage through an  
employer-sponsored, self-insured health plan must complete  
Form 1095-C, Parts I, II, and III, for any employee who enrolls in  
the health coverage, whether or not the employee is a full-time  
employee for any month of the calendar year.  
For full-time employees enrolled in an ALE Member’s  
self-insured coverage, including an employee who was a  
full-time employee for at least 1 month of the calendar year, the  
ALE Member must complete Form 1095-C, Part II, according to  
the generally applicable instructions, and should not enter code  
1G on line 14 for any month. For an employee enrolled in an ALE  
Member’s self-insured coverage who is not a full-time employee  
for any month of the calendar year (meaning that for all 12  
calendar months the employee was not a full-time employee), for  
Form 1095-C, Part II, the ALE Member must enter code 1G on  
line 14 in the “All 12 Months” column or in the separate monthly  
boxes for all 12 calendar months, and the ALE Member need not  
complete Part II, lines 15 and 16.  
Authoritative Transmittal for ALE  
Members Filing Multiple Forms 1094-C  
A Form 1094-C must be filed when an ALE Member files one or  
more Forms 1095-C. An ALE Member may choose to file  
multiple Forms 1094-C, each accompanied by Forms 1095-C for  
a portion of its employees, provided that a Form 1095-C is filed  
for each employee for whom the ALE Member is required to file.  
If an ALE Member files more than one Form 1094-C, one (and  
only one) Form 1094-C filed by the ALE Member must be  
identified on line 19, Part I, as the Authoritative Transmittal, and,  
on the Authoritative Transmittal, the ALE Member must report  
certain aggregate data for all full-time employees and all  
employees, as applicable, of the ALE Member.  
Example 1. Employer A, an ALE Member, files a single Form  
1094-C, attaching Forms 1095-C for each of its 100 full-time  
employees. This Form 1094-C should be identified as the  
Authoritative Transmittal on line 19, and the remainder of the  
form completed as indicated in the instructions for line 19, later.  
An individual coverage HRA is a self-insured group  
health plan and is therefore an eligible  
TIP  
employer-sponsored plan. An individual is ineligible for a  
premium tax credit (PTC) for a month if the individual is covered  
by an individual coverage HRA or eligible for an individual  
coverage HRA that is affordable.  
Example 2. Employer B, an ALE Member, files two Forms  
1094-C, one for each of its two operating divisions, Division X  
and Division Y. (Division X and Division Y are units of the same  
ALE Member, and thus both report under the same employer  
identification number (EIN); they are not members of an  
Aggregated ALE Group.) Attached to one Form 1094-C are  
Forms 1095-C for the 200 full-time employees of Division X, and  
attached to the other Form 1094-C are Forms 1095-C for the  
1,000 full-time employees of Division Y. One of these Forms  
1094-C should be identified as the Authoritative Transmittal on  
line 19, and should include aggregate employer-level data for all  
1,200 full-time employees of Employer B as well as the total  
number of employees of Employer B, as applicable, as required  
in Parts II, III, and IV of Form 1094-C. The other Form 1094-C  
should not be identified as the Authoritative Transmittal on  
line 19, and should report on line 18 only the number of Forms  
1095-C that are attached to that Form 1094-C, and should leave  
the remaining sections of the form blank, as indicated in the  
instructions for line 19, later.  
An employer that offers employer-sponsored, self-insured  
health coverage but is not an ALE Member should not file Forms  
1094-C and 1095-C, but should instead file Forms 1094-B and  
1095-B to report information for employees who enrolled in the  
employer-sponsored, self-insured health coverage.  
Note. If an ALE Member is offering health coverage to  
employees other than under a self-insured plan, such as through  
an insured health plan or a multiemployer health plan, the issuer  
of the insurance or the sponsor of the plan providing the  
coverage is required to furnish the information about their health  
coverage to any enrolled employees, and the ALE Member  
should not complete Form 1095-C, Part III, for those employees.  
Reporting of Enrollment Information  
for Non-Employees: Option  
To Use Forms 1094-B and 1095-B  
ALE Members that offer employer-sponsored, self-insured  
health coverage to non-employees who enroll in the coverage  
may use Forms 1094-B and 1095-B, rather than Form 1095-C,  
Part III, to report coverage for those individuals and other family  
members. For this purpose, a non-employee includes, for  
example, a non-employee director, an individual who was a  
retired employee during the entire year, or a non-employee  
COBRA beneficiary, including a former employee who  
terminated employment during a previous year.  
Note. Each ALE Member must file its own Forms 1094-C and  
1095-C under its own separate EIN, even if the ALE Member is  
part of an Aggregated ALE Group. No Authoritative Transmittal  
should be filed for an Aggregated ALE Group.  
Example 3. Assume that Employer A from Example 1 is a  
member of the same Aggregated ALE Group as Employer B  
from Example 2. Accordingly, Employer A and Employer B are  
separate ALE Members filing under separate EINs. Forms  
1094-C should be filed in the same manner indicated in  
Examples 1 and 2. Employer A should include only information  
about employees of Employer A in its Authoritative Transmittal,  
and Employer B should include only information about  
employees of Employer B in its Authoritative Transmittal. No  
Authoritative Transmittal should be filed for the Aggregated ALE  
Group reporting combined data for employees of both Employer  
A and Employer B.  
For information on reporting for non-employees enrolled in an  
employer-sponsored, self-insured health plan using Forms  
1094-B and 1095-B, see the instructions for those forms.  
For ALE Members that choose to use Form 1095-C to report  
coverage information for non-employees enrolled in an  
employer-sponsored, self-insured health plan, see the specific  
instructions for Form 1095-C, Part III—Covered Individuals  
(Lines 18–30), later. Form 1095-C may be used only if the  
individual identified on line 1 has an SSN.  
Similar rules apply for a Governmental Unit that has  
delegated its reporting responsibilities for some of its employees  
-2-  
Instructions for Forms 1094-C and 1095-C (2023)  
 
to another Governmental Unit—see Designated Governmental  
Entity (DGE) in the Definitions section of these instructions for  
more information. In the case of a Governmental Unit that has  
delegated its reporting responsibilities for some of its employees,  
the Governmental Unit must ensure that among the multiple  
Forms 1094-C filed by or on behalf of the Governmental Unit  
transmitting Forms 1095-C for the Governmental Unit’s  
employees, one of the filed Forms 1094-C is designated as the  
Authoritative Transmittal and reports aggregate employer-level  
data for the Governmental Unit, as required in Parts II, III, and IV  
of Form 1094-C.  
Example. County is an Aggregated ALE Group made up of  
the ALE Members School District, the Police District, and the  
County General Office. The School District designates the state  
to report on behalf of the teachers and reports for itself for its  
remaining full-time employees. In this case, either the School  
District or the state must file an Authoritative Transmittal  
reporting aggregate employer-level data for the School District.  
employees reported for those months on Form 1094-C. For the  
months April through December, on Form 1095-C, Employer A  
should enter code 1H (no offer of coverage) on line 14, leave  
line 15 blank, and enter code 2A (not an employee) on line 16  
(since Employee is treated as an employee of Employer B and  
not as an employee of Employer A in those months), and should  
exclude Employee from the count of total employees and  
full-time employees reported for those months on Form 1094-C.  
When To File  
You will meet the requirement to file Forms 1094-C and 1095-C if  
the forms are properly addressed and mailed on or before the  
due date. If the due date falls on a weekend or legal holiday, then  
the due date is the following business day. A business day is any  
day that is not a Saturday, Sunday, or legal holiday.  
Generally, you must file Forms 1094-C and 1095-C by  
February 28 if filing on paper (or March 31 if filing electronically)  
of the year following the calendar year to which the return  
relates. For calendar year 2023, Forms 1094-C and 1095-C are  
required to be filed by February 28, 2024, or April 1, 2024, if filing  
electronically.  
One Form 1095-C for Each  
Employee of ALE Member  
For each full-time employee of an ALE Member, there must be  
only one Form 1095-C filed for employment with that ALE  
Member. For example, if an ALE Member separately reports for  
each of its two divisions, the ALE Member must combine the  
offer and coverage information for any employee who worked at  
both divisions during the calendar year so that a single Form  
1095-C is filed for the calendar year for that employee, which  
reports information for all 12 months of the calendar year from  
that ALE Member.  
on when Form 1095-C must be furnished.  
Extensions  
You can get an automatic 30-day extension of time to file by  
completing Form 8809, Application for Extension of Time To File  
Information Returns. The form may be submitted on paper, or  
through the FIRE System either as a fill-in form or an electronic  
file. No signature or explanation is required for the extension.  
However, you must file Form 8809 on or before the due date of  
the returns in order to get the 30-day extension. Under certain  
hardship conditions, you may apply for an additional 30-day  
extension. See the Instructions for Form 8809 for more  
information.  
In contrast, a full-time employee who works for more than one  
ALE Member that is a member of the same Aggregated ALE  
Group must receive a separate Form 1095-C from each ALE  
Member. For any calendar month in which a full-time employee  
works for more than one ALE Member of an Aggregated ALE  
Group, only one ALE Member is treated as the employer of that  
employee for reporting purposes (generally, the ALE Member for  
whom the employee worked the greatest number of hours of  
service), and only that ALE Member reports for that employee for  
that calendar month. The other ALE Member is not required to  
report for that employee for that calendar month, unless the  
other ALE Member is otherwise required to file Form 1095-C for  
that employee because the individual was a full-time employee  
of that ALE Member for a different month of the same calendar  
year. In this case, the individual may be treated as not employed  
by that ALE Member for that calendar month. If under these  
rules, an ALE Member is not required to report for an employee  
for any month in the calendar year, the ALE Member is not  
required to report for that full-time employee for that calendar  
year. For a description of the rules related to determining which  
ALE Member in an Aggregated ALE Group is treated as the  
employer for a month in this situation, see the definition of  
How to apply. File Form 8809 as soon as you know that a  
30-day extension of time to file is needed. See the instructions  
for Form 8809. Mail or fax Form 8809 using the address and  
phone number listed in the instructions. You can also submit the  
extension request online through the FIRE System. You are  
encouraged to submit requests using the online fill-in form. See  
Pub. 1220 for more information on filing online or electronically.  
Where To File  
Send all information returns filed on paper to the following:  
If your principal business,  
office or agency, or legal  
Use the following address:  
residence, in the case of an  
individual, is located in:  
Example. Employer A and Employer B are separate ALE  
Members that belong to the same Aggregated ALE Group. Both  
Employer A and Employer B offer coverage through the AB  
health plan, which is an insured plan. In January and February,  
Employee has 130 hours of service for Employer A and no hours  
of service for Employer B. In March, Employee has 100 hours of  
service for Employer A and 30 hours of service for Employer B.  
In April through December, Employee has 130 hours of service  
for Employer B and no hours of service for Employer A.  
Alabama, Arizona, Arkansas,  
Connecticut, Delaware, Florida,  
Georgia, Kentucky, Louisiana,  
Maine, Massachusetts,  
Mississippi, New Hampshire,  
New Jersey, New Mexico, New  
York, North Carolina, Ohio,  
Pennsylvania, Rhode Island,  
Texas, Vermont, Virginia,  
West Virginia  
Department of the Treasury  
Internal Revenue Service  
Center  
Austin, TX 73301  
Employer A is the employer of Employee for filing purposes for  
January, February, and March. Employer A should file Form  
1095-C for Employee reporting offers of coverage using the  
appropriate code on line 14 for January, February, and March;  
should complete lines 15 and 16 per the instructions; and should  
include Employee in the count of total employees and full-time  
-3-  
Instructions for Forms 1094-C and 1095-C (2023)  
 
you establish reasonable cause. However, you can file up to 10  
returns on paper; those returns will not be subject to a penalty for  
failure to file electronically. The penalty applies separately to  
original returns and corrected returns.  
If your principal business,  
office or agency, or legal  
residence, in the case of an  
individual, is located in:  
Use the following address:  
Pub. 5165, Guide for Electronically Filing Affordable Care Act  
(ACA) Information Returns for Software Developers and  
Transmitters, specifies the communication procedures,  
transmission formats, business rules, and validation procedures,  
and explains when a return will be accepted, accepted with  
errors, or rejected, for returns filed electronically for calendar  
year 2023 through the ACA Information Return (AIR) system. To  
develop software for use with the AIR system, software  
developers, transmitters, and issuers, including ALE Members  
filing their own Forms 1094-C and 1095-C, should use the  
guidelines provided in Pub. 5165 along with the Extensible  
Markup Language (XML) Schemas published on IRS.gov.  
Alaska, California, Colorado,  
District of Columbia, Hawaii,  
Idaho, Illinois, Indiana, Iowa,  
Kansas, Maryland, Michigan,  
Minnesota, Missouri, Montana,  
Nebraska, Nevada, North  
Dakota, Oklahoma, Oregon,  
South Carolina, South Dakota,  
Tennessee, Utah, Washington,  
Wisconsin, Wyoming  
Department of the Treasury  
Internal Revenue Service  
Center  
P.O. Box 219256  
Kansas City, MO 64121-9256  
Reminder. The formatting directions in these instructions (for  
example, the directions to enter the 9-digit EIN, including the  
dash on line 2 of Form 1094-C) are for the preparation of paper  
returns. When filing forms electronically, the formatting set forth  
in the XML Schemas and Business Rules published on IRS.gov  
must be followed rather than the formatting directions in these  
instructions. For more information regarding electronic filing, see  
Pubs. 5164 and 5165.  
If your legal residence or principal place of business or  
principal office or agency is outside the United States, file with  
the Department of the Treasury, Internal Revenue Service  
Center, Austin, TX 73301.  
Shipping and mailing. If you are filing on paper, send the  
forms to the IRS in a flat mailing (not folded), and do not  
paperclip or staple the forms together. If you are sending many  
forms, you may send them in conveniently sized packages. On  
each package, write your name, number the packages  
consecutively, and place Form 1094-C in package number one.  
Postal regulations require forms and packages to be sent by  
First-Class Mail. Returns filed with the IRS must be printed in  
landscape format.  
Substitute Returns Filed With the IRS  
If you are filing your returns on paper, see Pub. 5223 for  
specifications for private printing of substitute information  
returns. You may not request special consideration. Only forms  
that conform to the official form and the specifications in Pub.  
5223 are acceptable for filing with the IRS. Substitute returns  
filed with the IRS must be printed in landscape format.  
Keeping copies. Generally, keep copies of information returns  
you filed with the IRS or have the ability to reconstruct the data  
for at least 3 years, from the due date of the returns.  
VOID Box  
Do not use this box on Form 1095-C.  
Corrected Forms 1094-C and 1095-C  
Electronic Filing  
For information about filing corrections electronically, see  
If you are required to file 10 or more  
section 7.1 of Pub. 5165.  
TIP  
information returns during the year, you  
must file the forms electronically. The  
10-or-more requirement applies in the aggregate to certain  
information returns that are original or corrected returns.  
Accordingly, a filer may be required to file fewer than 10 Forms  
1094-C and 1095-C, but still have an electronic filing obligation  
based on other kinds of information returns filed. The electronic  
filing requirement does not apply if you request and receive a  
hardship waiver. The IRS encourages you to file electronically  
even though you are filing fewer than 10 returns.  
Corrected Returns  
A corrected return should be filed as soon as possible after an  
error is discovered. File the corrected returns as follows.  
Form 1094-C. If correcting information on the Authoritative  
Transmittal (identified on Part I, line 19, as the Authoritative  
Transmittal, one (and only one) of which must be filed for each  
ALE Member reporting aggregate employer-level data for all  
full-time employees and employees of the ALE Member), file a  
standalone, fully completed Form 1094-C, including the correct  
information, and enter an “X” in the “CORRECTED” checkbox.  
Do not file a return correcting information on a Form 1094-C that  
is not the Authoritative Transmittal.  
Waiver. To receive a waiver from the required filing of  
information returns electronically, submit Form 8508. You are  
encouraged to file Form 8508 at least 45 days before the due  
date of the returns, but no later than the due date of the return.  
The IRS does not process waiver requests until January 1 of the  
calendar year the returns are due. You cannot apply for a waiver  
for more than 1 tax year at a time. If you need a waiver for more  
than 1 tax year, you must reapply at the appropriate time each  
year. If a waiver for original returns is approved, any corrections  
for the same types of returns will be covered under the waiver.  
However, if you submit original returns electronically but you  
want to submit your corrections on paper, a waiver must be  
approved for the corrections if you must file 10 or more  
corrections. If you receive an approved waiver, do not send a  
copy of it to the service center where you file your paper returns.  
Keep the waiver for your records only.  
Do not file any other documents (for example, Form  
1095-C) with the corrected Authoritative Transmittal.  
!
CAUTION  
Form 1095-C. If correcting information on a Form 1095-C that  
was previously filed with the IRS, file a fully completed Form  
1095-C, including the correct information and enter an “X” in the  
“CORRECTED” checkbox. File a Form 1094-C (do not mark the  
“CORRECTED” checkbox on Form 1094-C) with corrected  
Form(s) 1095-C. Furnish the employee a copy of the corrected  
Form 1095-C, unless the ALE Member was, and continues to be,  
eligible for and used the alternative method of furnishing under  
the Qualifying Offer Method for that employee for that year’s  
furnishing. For more information, see Alternative method of  
If you are required to file electronically but fail to do so, and  
you do not have an approved waiver, you may be subject to a  
penalty of $310 per return for failure to file electronically unless  
-4-  
Instructions for Forms 1094-C and 1095-C (2023)  
 
Original Authoritative Transmittal Form 1094-C  
Method.  
IF any of the following are  
THEN ...  
incorrect ...  
Forms 1095-C filed with incorrect dollar amounts on line 15,  
Employee Required Contribution, may fall under a safe harbor  
for certain de minimis errors. The safe harbor generally applies if  
no single amount in error differs from the correct amount by more  
than $100. If the safe harbor applies, you will not have to correct  
Form 1095-C to avoid penalties. However, if the recipient elects  
for the safe harbor not to apply, you may have to issue a  
corrected Form 1095-C to avoid penalties. For more information,  
see Notice 2017-9, 2017-4 I.R.B. 542, at IRS.gov/irb/2017-04  
ALE Member or Designated  
Government Entity (Name and/or  
EIN)  
1. Prepare a new Authoritative  
Transmittal, Form 1094-C.  
2. Enter an “X” in the “CORRECTED”  
checkbox at the top of the form.  
Total number of Forms 1095-C filed  
by and/or on behalf of ALE Member  
3. Submit the standalone corrected  
Form 1094-C with the correct  
information present.  
Note. Enter an “X” in the “CORRECTED” checkbox only when  
correcting a Form 1095-C previously filed with the IRS. If you are  
correcting a Form 1095-C that was previously furnished to a  
recipient, but not filed with the IRS, write, type, or print  
“CORRECTED” on the new Form 1095-C furnished to the  
recipient.  
Aggregated ALE Group Membership  
Certifications of Eligibility  
Minimum Essential Coverage Offer  
Indicator  
Correcting information affecting statement furnished to  
employee using an Alternative Furnishing Method under  
the Qualifying Offer Method. If an ALE Member eligible to use  
the Qualifying Offer Method had furnished the employee an  
alternative statement, the ALE Member must furnish the  
employee a corrected statement if it filed a corrected Form  
1095-C correcting the ALE Member’s name, EIN, address, or  
contact name and telephone number. If the ALE Member is no  
longer eligible to use an alternative furnishing method for the  
employee for whom it filed a corrected Form 1095-C, it must  
furnish a Form 1095-C to the employee and advise the employee  
that Form 1095-C replaces the statement it had previously  
furnished.  
Section 4980H Full-Time Employee  
Count for ALE Member  
Aggregated Group Indicator  
Other ALE Members of Aggregated  
ALE Group (Name and/or EIN)  
Original Form 1095-C Submitted to IRS and Furnished to Employee  
IF any of the following are  
incorrect ...  
THEN ...  
If you fail to file correct information returns or fail to  
furnish a correct recipient statement, you may be subject  
!
CAUTION  
to a penalty. However, you are not required to file  
Name, SSN, ALE Member EIN  
Offer of Coverage (line 14)  
1. Prepare a new Form 1095-C.  
corrected returns for missing or incorrect TINs if you meet the  
reasonable cause criteria. For additional information, see Pub.  
1586, Reasonable Cause Regulations and Requirements for  
Missing and Incorrect Name/TINs on Information Returns.  
2. Enter an “X” in the “CORRECTED”  
checkbox at the top of the form.  
Employee Required Contribution  
3. Submit corrected Forms 1095-C with  
a non-authoritative Form 1094-C  
transmittal to the IRS.  
See the charts for examples of errors and step-by-step  
instructions for filing corrected returns.  
TIP  
Section 4980H Safe Harbor and  
Other Relief Codes (line 16)  
4. Furnish a corrected Form 1095-C to  
the employee.  
Covered Individuals Information  
-5-  
Instructions for Forms 1094-C and 1095-C (2023)  
A statement may be furnished electronically by email or by  
informing the individual how to access the statement on the ALE  
Member’s website. Statements reporting coverage and offers of  
coverage under an expatriate health plan, however, may be  
furnished electronically unless the recipient explicitly refuses to  
consent to receive the statement in an electronic format. Specific  
information on consents to furnish statements electronically can  
be found in Regulations section 301.6056-2.  
Original Alternative Furnishing Method Under the Qualifying Offer  
Method Statement Furnished to Employee  
IF any of the following are  
incorrect ...  
THEN ...  
Name, SSN, ALE Member EIN  
Offer of Coverage  
• Submission to the IRS:  
1. Prepare a new Form 1095-C.  
2. Enter an “X” in the “CORRECTED”  
checkbox at the top of the form.  
Extensions of time to furnish statements to recipients. The  
due date for furnishing Form 1095-C is automatically extended  
from January 31, 2024, to March 1, 2024. Thus, no additional  
extensions will be granted.  
3. Submit corrected Form 1095-Cs  
with a non-authoritative Form 1094-C  
transmittal to the IRS.  
Information reporting penalties. All employers subject to the  
employer shared responsibility provisions and other employers  
that sponsor self-insured group health plans that fail to comply  
with the applicable information reporting requirements may be  
subject to the general reporting penalty provisions for failure to  
file correct information returns and failure to furnish correct  
payee statements. For returns required to be made and  
statements required to be furnished for 2023 tax year returns, the  
following apply.  
• Furnish to employee:  
If, after the correction, the ALE Member  
is still eligible to use the alternative  
furnishing method under the Qualifying  
Offer Method, furnish the employee  
either a Form 1095-C or corrected  
statement.  
If the ALE Member is no longer eligible  
to use the alternative furnishing method  
with respect to the employee, furnish a  
Form 1095-C to the employee.  
The penalty for failure to file a correct information return is  
$310 for each return for which the failure occurs, with the total  
penalty for a calendar year not to exceed $3,783,000.  
The penalty for failure to provide a correct payee statement is  
$310 for each statement for which the failure occurs, with the  
total penalty for a calendar year not to exceed $3,783,000.  
Furnishing Forms 1095-C to Employees  
Special rules apply that increase the per-statement and total  
You will meet the requirement to furnish Form 1095-C to an  
employee if the form is properly addressed and mailed on or  
before the due date. If the due date falls on a weekend or legal  
holiday, then the due date is the following business day. A  
business day is any day that is not a Saturday, Sunday, or legal  
holiday.  
penalties if there is intentional disregard of the requirement to file  
the returns and furnish the required statements.  
Penalties may be waived if the failure was due to reasonable  
cause and not willful neglect. See section 6724 and Regulations  
section 301.6724-1 and Regulations section 1.6055-1(h) (which  
relate to Form 1095-C, Part III). For additional information, see  
Pub. 1586.  
An ALE member must furnish a Form 1095-C to each of its  
full-time employees by March 1, 2024, for the 2023 calendar  
below.  
Alternative manner of furnishing statements to  
non-full-time employees. If you are an ALE member that offers  
employer-sponsored, self-insured health coverage and meets  
the requirements of Regulations section 1.6055-1(g), you may  
use the alternative manner of furnishing statements to  
For more information on alternative furnishing methods for  
employers, see Qualifying Offer Method, later.  
non-full-time employees and non-employees who are enrolled in  
the self-insured health coverage. To use the alternative manner  
of furnishing statements, the following conditions must be met.  
Filers of Form 1095-C may truncate the social security  
number (SSN) of an individual (the employee or any family  
member of the employee receiving coverage) on Form 1095-C  
statements furnished to employees by showing only the last four  
digits of the SSN and replacing the first five digits with asterisks  
(*) or Xs. Truncation is not allowed on forms filed with the IRS. In  
addition, an ALE Member's EIN may not be truncated on the  
statements furnished to employees or the forms filed with the  
IRS.  
The employer must provide clear and conspicuous notice, in a  
location on its website that is reasonably accessible to all  
individuals, stating that individuals may receive a copy of their  
statement upon request. The notice must include an email  
address, a physical address to which a request for a statement  
may be sent, and a telephone number that individuals may use  
to contact the employer with any questions. A notice posted on  
an employer’s website must be written in plain, non-technical  
terms and with letters of a font size large enough, including any  
visual clues or graphical figures, to call to a viewer’s attention  
that the information pertains to tax statements reporting that  
individuals had health coverage. For example, an employer’s  
website provides a clear and conspicuous notice if it (1) includes  
a statement on the main page, or a link on the main page,  
reading “Tax Information,to a secondary page that includes a  
statement, in capital letters, “IMPORTANT HEALTH COVERAGE  
TAX DOCUMENTS”; (2) explains how non-full-time employees  
and non-employees who are enrolled in the plan may request a  
copy of Form 1095-C; and (3) includes the employer’s email  
address, mailing address, and telephone number.  
Except as provided below, statements must be furnished on  
paper by mail (or hand delivered), unless the recipient  
affirmatively consents to receive the statement in an electronic  
format. If mailed, the statement must be sent to the employee's  
last known permanent address, or if no permanent address is  
known, to the employee's temporary address. For more  
information on furnishing statements to non-full-time employees  
and non-employees who are enrolled in employer-sponsored  
self-insured health coverage, see Alternative manner of  
Consent to furnish statement electronically. An ALE  
Member is required to obtain affirmative consent to furnish a  
statement electronically. This requirement ensures that  
The employer must post the notice on its website by March 1,  
statements are furnished electronically only to individuals who  
are able to access them. The consent must relate specifically to  
receiving the Form 1095-C electronically. An individual may  
consent on paper or electronically, such as by email. If consent is  
on paper, the individual must confirm the consent electronically.  
2024, and retain the notice in the same location on its website  
through October 15, 2024.  
The employer must furnish the statement to a requesting  
individual within 30 days of the date the request is received. To  
-6-  
Instructions for Forms 1094-C and 1095-C (2023)  
     
satisfy this requirement, the employer may furnish the statement  
electronically if the recipient affirmatively consents.  
employer-level data for the ALE Member and be identified on  
line 19 as the Authoritative Transmittal. If multiple Forms 1094-C  
are being filed for an ALE Member so that Forms 1095-C for all  
full-time employees of the ALE Member are not attached to a  
single Form 1094-C transmittal (because Forms 1095-C for  
some full-time employees of the ALE Member are being  
transmitted separately), one (and only one) of the Forms 1094-C  
must report aggregate employer-level data for the ALE Member  
and be identified on line 19 as the Authoritative Transmittal. For  
Specific Instructions for Form 1094-C  
Part I—Applicable Large Employer Member  
(ALE Member)  
Line 1. Enter employer's name. The employer is the ALE  
Member.  
Line 2. Enter the ALE Member’s EIN. Do not enter an SSN.  
Part II—ALE Member Information  
Enter the 9-digit EIN, including the dash.  
If you are filing Form 1094-C, a valid EIN is required at  
Reminder. Lines 20–22 should be completed only on the  
Authoritative Transmittal for the ALE Member. For more  
the time the form is filed. If a valid EIN is not provided,  
!
CAUTION  
Form 1094-C will not be processed. If you do not have  
an EIN, you may apply for one online. Go to IRS.gov/EIN. You  
may also apply by faxing or mailing Form SS-4, Application for  
Employer Identification Number, to the IRS. See the Instructions  
for Form SS-4 and Pub. 1635, Employer Identification Number.  
Line 20. Enter the total number of Forms 1095-C that will be  
filed by, and/or on behalf of, the ALE Member. This includes all  
Forms 1095-C that are filed with this transmittal, including those  
filed for individuals who enrolled in the employer-sponsored,  
self-insured plan, if any, and for any Forms 1095-C filed with a  
separate transmittal filed by, or on behalf of, the ALE Member.  
Lines 3–6. Enter the ALE Member’s complete address  
(including room or suite no., if applicable). This address should  
match the ALE Member’s address used on Form 1095-C.  
Line 21. If during any month of the calendar year the ALE  
Member was a member of an Aggregated ALE Group, check  
Yes.If you check “Yes,also complete the “Aggregated Group  
Indicator” in Part III, column (d), and then complete Part IV to list  
the other members of the Aggregated ALE Group. If, for all 12  
months of the calendar year, the employer was not a member of  
an Aggregated ALE Group, check “No,and do not complete  
Part III, column (d), or Part IV.  
Lines 7 and 8. Enter the name and telephone number of the  
person to contact who is responsible for answering any  
questions from the IRS regarding the filing of, or information  
reported on, Form 1094-C or 1095-C. This may be different than  
the contact information on line 10 of Form 1095-C.  
Note. If you are a Designated Governmental Entity (DGE) filing  
on behalf of an ALE Member, complete lines 9–16. If you are not  
a DGE filing on behalf of an ALE Member, do not complete lines  
9–16. Instead, skip to line 18. See Designated Governmental  
Entity (DGE) in the Definitions section of these instructions.  
Line 22. If the ALE Member meets the eligibility requirements  
and is using one of the Offer Methods, it must check the  
applicable box. See the descriptions of Qualifying Offer Method  
and 98% Offer Method, later.  
Line 9. If a DGE is filing on behalf of the ALE Member, enter the  
A. Qualifying Offer Method. Check this box if the ALE  
Member is eligible to use, and is using, the Qualifying Offer  
Method to report the information on Form 1095-C for one or  
more full-time employees. Under the Qualifying Offer Method,  
there is an alternative method of completing Form 1095-C and  
an alternative method for furnishing Form 1095-C to certain  
employees. If the ALE Member is using either of these  
alternative rules, check this box. To be eligible to use the  
Qualifying Offer Method, the ALE Member must certify that it  
made a Qualifying Offer to one or more of its full-time employees  
for all months during the year in which the employee was a  
full-time employee for whom an employer shared responsibility  
payment could apply. Additional requirements described below  
must be met to be eligible to use the alternative method for  
furnishing Form 1095-C to employees under the Qualifying Offer  
Method.  
Alternative method of completing Form 1095-C under  
the Qualifying Offer Method. If the ALE Member reports using  
this method, it must not complete Form 1095-C, Part II, line 15,  
for any month for which a Qualifying Offer is made. Instead, it  
must enter the Qualifying Offer code 1A on Form 1095-C,  
line 14, for any month for which the employee received a  
Qualifying Offer (or in the “ All 12 Months” box if the employee  
received a Qualifying Offer for all 12 months), and must leave  
line 15 blank for any month for which code 1A is entered on  
line 14. The ALE Member may, but is not required to, enter an  
applicable code on line 16 for any month for which code 1A is  
entered on line 14; a Qualifying Offer is, by definition, treated as  
an offer that falls within an affordability safe harbor even if no  
code is entered on line 16.  
name of the DGE.  
Line 10. Enter the DGE’s EIN (including the dash). Do not enter  
an SSN.  
If you are a DGE that is filing Form 1094-C, a valid EIN is  
required at the time the return is filed. If a valid EIN is not  
!
CAUTION  
provided, the return will not be processed. If the DGE  
does not have an EIN when filing Form 1094-C, it can get an EIN  
by applying online at IRS.gov/EIN or by faxing or mailing a  
completed Form SS-4. See the Instructions for Form SS-4 and  
Pub. 1635.  
Lines 11–14. Enter the DGE’s complete address (including  
room or suite no.).  
Lines 15 and 16. Enter the name and telephone number of the  
person to contact who is responsible for answering any  
questions from the IRS regarding the filing of, or information  
reported on, Form 1094-C.  
Line 17. Reserved for future use.  
Line 18. Enter the total number of Forms 1095-C submitted with  
this Form 1094-C transmittal.  
Line 19. If this Form 1094-C transmittal is the Authoritative  
Transmittal that reports aggregate employer-level data for the  
ALE Member, check the box on line 19 and complete Parts II, III,  
and IV, to the extent applicable. Otherwise, complete the  
signature portion of Form 1094-C and leave the remainder of  
Parts II, III, and IV blank.  
There must be only one Authoritative Transmittal filed for each  
ALE Member. If this is the only Form 1094-C being filed for the  
ALE Member, this Form 1094-C must report aggregate  
An ALE Member is not required to use the Qualifying Offer  
Method even if it is eligible, and instead may enter on line 14 the  
-7-  
Instructions for Forms 1094-C and 1095-C (2023)  
   
applicable offer code and then enter on line 15 the Employee  
Required Contribution.  
Non-Assessment Period, the ALE Member offered affordable  
health coverage providing minimum value to at least 98% of its  
employees for whom it is filing a Form 1095-C employee  
statement, and offered minimum essential coverage to those  
employees’ dependents. The ALE Member is not required to  
identify which of the employees for whom it is filing were full-time  
employees, but the ALE Member is still required, under the  
general reporting rules, to file Forms 1095-C on behalf of all its  
full-time employees who were full-time employees for one or  
more months of the calendar year. To ensure compliance with  
the general reporting rules, an ALE Member should confirm for  
any employee for whom it fails to file a Form 1095-C that the  
employee was not a full-time employee for any month of the  
calendar year. For this purpose, the health coverage is affordable  
if the ALE Member meets one of the section 4980H affordability  
safe harbors.  
Example. Employer has 325 employees. Of those 325  
employees, Employer identifies 25 employees as not possibly  
being full-time employees because they are scheduled to work  
10 hours per week and are not eligible for additional hours. Of  
the remaining 300 employees, 295 are offered affordable  
minimum value coverage for all periods during which they are  
employed other than any applicable waiting period (which  
qualifies as a Limited Non-Assessment Period). Employer files a  
Form 1095-C for each of the 300 employees (excluding the 25  
employees that it identified as not possibly being full-time  
employees). Employer may use the 98% Offer Method because  
it makes an affordable offer of coverage that provides minimum  
value to at least 98% of the employees for whom Employer files  
a Form 1095-C. Using this method, Employer does not identify  
whether each of the 300 employees is a full-time employee.  
However, Employer must still file a Form 1095-C for all of its  
full-time employees. Employer chooses to file a Form 1095-C on  
behalf of all 300 employees, including the five employees to  
whom it did not offer coverage, because if one or more of those  
employees was, in fact, a full-time employee for one or more  
months of the calendar year, Employer would be required to  
have filed a Form 1095-C on behalf of those employees.  
If the ALE Member is eligible to use the Qualifying Offer  
Method, it may report on Form 1095-C by entering the  
Qualifying Offer code 1A on Form 1095-C, line 14, for  
TIP  
any month for which it made a Qualifying Offer to an employee,  
even if the employee did not receive a Qualifying Offer for all 12  
calendar months. However, if an employee receives a Qualifying  
Offer for less than all 12 months, the ALE Member must furnish a  
copy of Form 1095-C to the employee (rather than using the  
alternative method of furnishing Form 1095-C described later).  
Example. Employee’s employment with Employer begins on  
January 1. Employee is in a health coverage waiting period (and  
an employer shared responsibility payment could not apply with  
respect to Employee, because Employee is in a Limited  
Non-Assessment Period) until April 1 and is a full-time employee  
for the remainder of the calendar year. Employer makes a  
Qualifying Offer to Employee for coverage beginning on April 1  
and for the remainder of the calendar year. Employer is eligible  
to use the Qualifying Offer method because it has made a  
Qualifying Offer to at least one full-time employee for all months  
in which both (1) the employee was a full-time employee, and (2)  
an employer shared responsibility payment could apply with  
respect to the employee. Employer may use the alternative  
method of completing Form 1095-C under the Qualifying Offer  
Method for this Employee. However, Employer may not use the  
alternative method of furnishing Form 1095-C to Employee under  
the Qualifying Offer Method because Employee did not receive a  
Qualifying Offer for all 12 months of the calendar year.  
Alternative method of furnishing Form 1095-C to  
employees under the Qualifying Offer Method. An ALE  
Member that is eligible to use the Qualifying Offer Method may  
use the alternative method of furnishing Form 1095-C only for a  
full-time employee who (1) received a Qualifying Offer for all 12  
months of the calendar year, and (2) did not enroll in  
employer-sponsored, self-insured coverage. For such an  
employee, an ALE Member meets its obligation to furnish a Form  
1095-C to the employee if it furnishes the employee a statement  
containing the following information.  
Note. If an ALE Member uses the 98% offer method, it is not  
required to complete the “Section 4980H Full-Time Employee  
Count for ALE Member” in Part III, column (b).  
Employer/ALE Member name, address, and EIN.  
Contact name and telephone number at which the employee  
may receive information about the offer of coverage and the  
information on the Form 1095-C filed with the IRS for that  
employee.  
Part III—ALE Member Information—Monthly  
(Lines 23–35)  
Column (a)—Minimum Essential Coverage Offer Indicator.  
Notification that, for all 12 months of the calendar year, the  
employee and his or her spouse and dependents, if any,  
received a Qualifying Offer and therefore the employee is not  
eligible for a premium tax credit.  
If the ALE Member offered minimum essential coverage,  
including an individual coverage HRA, to at least 95% of its  
full-time employees and their dependents for the entire calendar  
year, enter “X” in the “Yes” checkbox on line 23 for “All 12  
Months” or for each of the 12 calendar months.  
Information directing the employee to see Pub. 974, Premium  
Tax Credit (PTC), for more information on eligibility for the  
premium tax credit.  
If the ALE Member offered minimum essential coverage,  
An ALE Member is not required to use the alternative method  
of furnishing for an employee even if the alternative method  
would be allowed. Instead, the ALE Member may furnish a copy  
of Form 1095-C as filed with the IRS (with or without the  
statement described earlier).  
As stated earlier, an ALE Member may not use the alternative  
furnishing method for a full-time employee who enrolled in  
self-insured coverage. Rather, the ALE Member must furnish  
Form 1095-C, including the information reporting enrollment in  
the coverage on Form 1095-C, Part III.  
B. Reserved for future use.  
C. Reserved for future use.  
D. 98% Offer Method. Check this box if the employer is  
eligible for, and is using, the 98% Offer Method. To be eligible to  
use the 98% Offer Method, an employer must certify that, taking  
into account all months during which the individuals were  
employees of the ALE Member and were not in a Limited  
including an individual coverage HRA, to at least 95% of its  
full-time employees and their dependents only for certain  
calendar months, enter “X” in the “Yes” checkbox for each  
applicable month.  
For the months, if any, for which the ALE Member did not offer  
minimum essential coverage, including an individual coverage  
HRA, to at least 95% of its full-time employees and their  
dependents, enter “X” in the “No” checkbox for each applicable  
month.  
If the ALE Member did not offer minimum essential coverage,  
including an individual coverage HRA, to at least 95% of its  
full-time employees and their dependents for any of the 12  
months, enter “X” in the “No” checkbox for “All 12 Months” or for  
each of the 12 calendar months.  
Note. For purposes of column (a), an employee in a Limited  
Non-Assessment Period is not counted in determining whether  
-8-  
Instructions for Forms 1094-C and 1095-C (2023)  
     
minimum essential coverage was offered to at least 95% of an  
ALE Member’s full-time employees and their dependents. For a  
description of the differences between the definition of the term  
“Limited Non-Assessment Period” used with respect to section  
4980H(a) and the definition used with respect to section  
4980H(b), relating to whether the ALE Member offers minimum  
value coverage at the end of the Limited Non-Assessment  
Period, see the Definitions section.  
employees in a Limited Non-Assessment Period, for each  
calendar month. An ALE Member must choose to use one of the  
following days of the month to determine the number of  
employees per month and must use that day for all months of the  
year: (1) the first day of each month, (2) the last day of each  
month, (3) the 12th day of each month, (4) the first day of the first  
payroll period that starts during each month, or (5) the last day of  
the first payroll period that starts during each month (provided  
that for each month that last day falls within the calendar month  
in which the payroll period starts). If the total number of  
An employee who is treated as having been offered  
health coverage, including an individual coverage HRA,  
for purposes of section 4980H (even though not actually  
TIP  
employees was the same for every month of the entire calendar  
year, enter that number in line 23, column (c), “All 12 Months,or  
in the boxes for each month of the calendar year. If the number  
of employees for any month is zero, enter -0-.  
offered) is treated as offered minimum essential coverage for this  
purpose. For example, for the months for which the ALE Member  
is eligible for multiemployer arrangement interim guidance (if the  
ALE Member is contributing on behalf of an employee whether  
or not the employee is eligible for coverage under the  
Column (d)—Aggregated Group Indicator. An ALE Member  
must complete this column if it checked “Yes” on line 21,  
multiemployer plan) with respect to an employee, that employee  
should be treated as having been offered minimum essential  
coverage for purposes of column (a). For different rules for  
purposes of reporting offers of coverage on Form 1095-C, see  
the specific instructions for Form 1095-C, Part II, line 14.  
indicating that, during any month of the calendar year, it was a  
member of an Aggregated ALE Group. If the ALE Member was a  
member of an Aggregated ALE Group during each month of the  
calendar year, enter “X” in the “All 12 Months” box or in the boxes  
for each of the 12 calendar months. If the ALE Member was not  
a member of an Aggregated ALE Group for all 12 months but  
was a member of an Aggregated ALE Group for one or more  
month(s), enter “X” in each month for which it was a member of  
an Aggregated ALE Group. If an ALE Member enters “X” in one  
or more months in this column, it must also complete Part IV.  
For purposes of column (a), if the ALE Member offered  
minimum essential coverage to all but five of its full-time  
employees and their dependents, and five is greater  
TIP  
than 5% of the number of full-time employees of the ALE  
Member, the ALE Member may report in column (a) as if it  
offered health coverage to at least 95% of its full-time employees  
and their dependents (even if it offered health coverage to less  
than 95% of its full-time employees and their dependents, for  
example, to 75 of its 80 full-time employees and their  
dependents).  
Part IV—Other ALE Members of  
Aggregated ALE Group (Lines 36–65)  
An ALE Member must complete this section if it checks “Yes” on  
line 21. If the ALE Member was a member of an Aggregated ALE  
Group (with other ALE Members) for any month of the calendar  
year, enter the name(s) and EIN(s) of up to 30 of the other  
Aggregated ALE Group members (not including the reporting  
ALE Member). If there are more than 30 members of the  
Aggregated ALE Group (not including the reporting ALE  
Member), enter the 30 with the highest monthly average number  
of full-time employees (using the number reported in Part III,  
column (b), if a number was required to be reported) for the year  
or for the number of months during which the ALE Member was  
a member of the Aggregated ALE Group. If any member of the  
Aggregated ALE Group uses the 98% Offer Method and thus is  
not required to identify which employees are full-time employees,  
all ALE Members of the Aggregated ALE Group should use the  
monthly average number of total employees rather than the  
monthly average number of full-time employees for this purpose.  
Regardless of the number of members in the Aggregated ALE  
Group, list only the 30 members in descending order, listing first  
the member with the highest average monthly number of full-time  
employees (or highest average number of total employees, if any  
member of the Aggregated ALE Group uses the 98% Offer  
Method), but do not include the reporting ALE Member. The  
reporting ALE Member must also complete Part III, column (d),  
to indicate which months it was part of an Aggregated ALE  
Group.  
See Definitions, later, for more information on an offer of  
health coverage.  
Column (b)—Section 4980H Full-Time Employee Count for  
ALE Member. Enter the number of full-time employees for each  
month, but do not count any employee in a Limited  
Non-Assessment Period. If the number of full-time employees  
(excluding employees in a Limited Non-Assessment Period) for a  
month is zero, enter -0-. An employee should be counted as a  
full-time employee for a month if the employee satisfied the  
definition of “full-time employee” under the monthly  
measurement method or the look-back measurement method  
(as applicable) on any day of the month. See Full-time employee  
and Limited Non-Assessment Period in the Definitions section.  
Be sure to use the section 4980H definition and not any other  
definition of the term “full-time employee” that you may use for  
other purposes.  
Example. Employer uses the look-back measurement  
method to determine the full-time status of its employees.  
Employee, who is not in a Limited Non-Assessment Period,  
averaged over 130 hours of service per month during the  
measurement period that corresponds with the stability period  
starting January 1, 2023, and ending December 31, 2023.  
Employee terminates employment with Employer on February  
15, 2023. Employer must include Employee in the number of  
full-time employees reported in column (b) for January and  
February. See the description of code 2B in the instructions for  
line 16 of Form 1095-C, later, for rules for reporting an offer of  
coverage in an employee’s final month of employment.  
If you are filing Form 1094-C, a valid EIN is required at  
the time it is filed. If a valid EIN is not provided, Form  
!
CAUTION  
1094-C will not be processed. If you do not have an EIN,  
you may apply for one online. Go to IRS.gov/EIN. You may also  
apply by faxing or mailing Form SS-4 to the IRS. See the  
Instructions for Form SS-4 and Pub. 1635.  
Note. If the ALE Member certified that it was eligible for the 98%  
Offer Method by selecting box D, on line 22, it is not required to  
complete column (b).  
Column (c)—Total Employee Count for ALE Member. Enter  
the total number of all of the ALE Member’s employees,  
including full-time employees and non-full-time employees, and  
-9-  
Instructions for Forms 1094-C and 1095-C (2023)  
plan), the employee does not actually have an offer of coverage  
for that month (and code 1H should therefore be entered on  
line 14). See line 16, code 2B, later, for how the ALE Member  
may complete line 16 in the event that coverage terminates  
before the last day of the month.  
A code must be entered for each calendar month, January  
through December, even if the employee was not a full-time  
employee for one or more of the calendar months. Enter the  
code identifying the type of health coverage actually offered by  
the ALE Member (or on behalf of the ALE Member) to the  
employee, if any. If the employee was not actually offered  
coverage, enter code 1H (no offer of coverage) on line 14.  
Specific Instructions for Form 1095-C  
Part I—Employee  
Line 1. Enter the name of the employee (first name, middle  
initial, last name).  
Line 2. Enter the 9-digit SSN of the employee (including the  
dashes).  
Lines 3–6. Enter the employee’s complete address, including  
apartment no., if applicable. A country code is not required for  
U.S. addresses.  
For reporting offers of coverage for 2023, an ALE Member  
relying on the multiemployer arrangement interim guidance  
should enter code 1H on line 14 for any month for which the ALE  
Member enters code 2E on line 16 (indicating that the ALE  
Member was required to contribute to a multiemployer plan on  
behalf of the employee for that month and therefore is eligible for  
multiemployer interim rule relief). For a description of the  
multiemployer arrangement interim guidance, see Offer of health  
coverage in the Definitions section. For reporting for 2023, code  
1H may be entered without regard to whether the employee was  
eligible to enroll, or enrolled in, coverage under the  
Part I—Applicable Large Employer Member  
(Employer)  
Line 7. Enter the name of the ALE Member.  
Line 8. Enter the ALE Member’s EIN. Do not enter an SSN.  
Enter the 9-digit EIN, including the dash. The ALE Member’s  
name and EIN should match the name and EIN of the ALE  
Member reported on lines 1 and 2 of Form 1094-C.  
If you are filing Form 1095-C, a valid EIN is required at  
multiemployer plan. For reporting for 2024 and future years, ALE  
Members relying on the multiemployer arrangement interim  
guidance may be required to report offers of coverage made  
through a multiemployer plan in a different manner.  
the time it is filed. If a valid EIN is not provided, Form  
!
CAUTION  
1095-C will not be processed. If you do not have an EIN,  
you may apply for one online. Go to IRS.gov/EIN. You may also  
apply by faxing or mailing Form SS-4 to the IRS. See the  
Instructions for Form SS-4 and Pub. 1635.  
Indicator Codes for Employee Offer of Coverage  
(Form 1095-C, Line 14)  
Lines 9 and 11–13. Enter the ALE Member’s complete address  
(including room or suite no., if applicable). This address should  
match the address reported on lines 3–6 of the Form 1094-C.  
Code Series 1—Offer of Coverage. The Code Series 1  
indicator codes specify the type of coverage, if any, offered to an  
employee, the employee’s spouse, and the employee’s  
dependents. The term Dependent has the specific meaning set  
forth in the Definitions section of these instructions. In addition,  
for this purpose, an offer of coverage is treated as made to an  
employee’s dependents only if the offer of coverage is made to  
an unlimited number of dependents regardless of the actual  
number of dependents, if any, an employee has during any  
particular calendar month.  
If the type of coverage, if any, offered to an employee was the  
same for all 12 months in the calendar year, enter the Code  
Series 1 indicator code corresponding to the type of coverage  
offered either in the “All 12 Months” box or in each of the 12  
boxes for the calendar months.  
Line 10. Enter the telephone number of the person to contact  
whom the recipient may call about the information reported on  
the form. This may be different than the contact information  
entered on line 8 of Form 1094-C.  
Part II—Employee Offer of Coverage  
Age. If the employee was offered an individual coverage HRA,  
enter the employee’s age on January 1, 2023. Note that for  
non-calendar year plans or for employees who become eligible  
during the plan year, this age may not be the Applicable age  
used to determine Employee Required Contribution.  
Plan Start Month. This box is required for the 2023 Form  
1095-C and the ALE Member may not leave it blank. To  
complete the box, enter the 2-digit number (01 through 12)  
indicating the calendar month during which the plan year begins  
of the health plan in which the employee is offered coverage (or  
would be offered coverage if the employee were eligible to  
participate in the plan). If more than one plan year could apply  
(for instance, if the ALE Member changes the plan year during  
the year), enter the earliest applicable month. If there is no health  
plan under which coverage is offered to the employee, enter “00.”  
Conditional offer of spousal coverage. Codes 1J and 1K  
address conditional offers of spousal coverage (also referred to  
as “coverage offered conditionally”). A conditional offer is an  
offer of coverage that is subject to one or more reasonable,  
objective conditions (for example, an offer to cover an  
employee’s spouse only if the spouse is not eligible for coverage  
under Medicare or a group health plan sponsored by another  
employer). Using codes 1J and 1K, an ALE Member may report  
a conditional offer to a spouse as an offer of coverage,  
regardless of whether the spouse meets the reasonable,  
objective condition. A conditional offer may impact a spouse's  
eligibility for the premium tax credit under section 36B only if all  
conditions to the offer are satisfied (that is, the spouse was  
actually offered the coverage and eligible for it) and the  
Exchange makes a determination about the affordability of the  
offer. To help employees (and spouses) who have received a  
conditional offer determine their eligibility for the premium tax  
credit, the ALE Member should be prepared to provide, upon  
request, a list of any and all conditions applicable to the spousal  
offer of coverage. As is noted in the definition of Dependent in  
the Definitions section, a spouse is not a dependent for  
purposes of section 4980H.  
Line 14. For each calendar month, enter the applicable code  
from Code Series 1. If the same code applies for all 12 calendar  
months, you may enter the applicable code in the “All 12 Months”  
box and not complete the individual calendar month boxes, or  
you may enter the code in each of the boxes for the 12 calendar  
months. If an employee was not offered coverage for a month,  
enter code 1H. Do not leave line 14 blank for any month  
(including months when the individual was not an employee of  
the ALE Member). An ALE Member offers health coverage for a  
month only if it offers health coverage that would provide  
coverage for every day of that calendar month. Thus, if coverage  
terminates before the last day of the month (because, for  
instance, the employee terminates employment with the ALE  
Member, or otherwise loses eligibility for coverage under the  
-10-  
Instructions for Forms 1094-C and 1095-C (2023)  
   
An ALE Member may not report a conditional offer of  
coverage to an employee’s dependents as an offer to the  
dependents, unless the ALE Member knows that the  
dependents met the condition to be eligible for the ALE  
Member’s coverage. Further, an offer of coverage is treated as  
made to an employee’s dependents only if the offer of coverage  
is made to an unlimited number of dependents regardless of the  
actual number of dependents, if any, an employee has during  
any particular calendar month.  
offer of coverage on line 14. If the ALE Member is otherwise  
required to file Form 1095-C for the former employee (because,  
for example, the individual was a full-time employee for one or  
more months in the calendar year in which the termination of  
employment occurred), the ALE Member should enter code 1H  
(no offer of coverage) on line 14 for any month to which an offer  
of post-employment coverage applies, and should also enter  
code 2A (not an employee) on line 16 (see the instructions for  
line 16).  
COBRA continuation coverage. An offer of COBRA  
continuation coverage is reported differently depending on  
whether or not the offer is made due to an employee’s  
termination of employment.  
For additional information, including examples about  
reporting offers of COBRA continuation coverage and  
post-employment coverage, go to IRS.gov/Affordable-  
TIP  
An offer of COBRA continuation coverage that is made to a  
former employee (or to a former employee’s spouse or  
1A. Qualifying Offer: Minimum essential coverage providing  
dependents) due to termination of employment should not be  
reported as an offer of coverage on line 14. In this situation, code  
1H (No offer of coverage) must be entered on line 14 for any  
month for which the offer of COBRA continuation coverage  
applies, and code 2A (Employee not employed during the  
month) must be entered on line 16 (see the instructions for  
line 16), without regard to whether the employee or spouse or  
dependents enrolled in the COBRA coverage. However, for the  
month in which the employee terminates employment with the  
ALE Member, see the instructions for line 16, code 2B.  
minimum value offered to full-time employee with Employee  
Required Contribution equal to or less than 9.5% (as adjusted) of  
mainland single federal poverty line and at least minimum  
essential coverage offered to spouse and dependent(s).  
This code may be used to report for specific months for  
which a Qualifying Offer was made, even if the employee  
did not receive a Qualifying Offer for all 12 months of the  
TIP  
calendar year. However, an ALE Member may not use the  
Alternative Furnishing Method for an employee who did not  
receive a Qualifying Offer for all 12 calendar months.  
An offer of COBRA continuation coverage that is made to an  
employee who remains employed by the ALE Member (or to that  
employee’s spouse and dependents) should be reported on  
line 14 as an offer of coverage, but only for any individual who  
receives an offer of COBRA continuation coverage (or an offer of  
similar coverage that is made at the same time as the offer of  
COBRA continuation coverage is made to enrolled individuals).  
Generally, an offer of COBRA continuation coverage is required  
to be made only to individuals who were enrolled in coverage  
and would lose eligibility for coverage due to the COBRA  
qualifying event, but an ALE Member may choose to extend a  
similar offer of coverage to a spouse or dependent even if the  
offer is not required by COBRA.  
1B. Minimum essential coverage providing minimum value  
offered to employee only.  
1C. Minimum essential coverage providing minimum value  
offered to employee and at least minimum essential coverage  
offered to dependent(s) (not spouse).  
1D. Minimum essential coverage providing minimum value  
offered to employee and at least minimum essential coverage  
offered to spouse (not dependent(s)). Do not use code 1D if the  
coverage for the spouse was offered conditionally. Instead, use  
code 1J.  
1E. Minimum essential coverage providing minimum value  
offered to employee and at least minimum essential coverage  
offered to dependent(s) and spouse. Do not use code 1E if the  
coverage for the spouse was offered conditionally. Instead, use  
code 1K.  
Example. During the applicable open enrollment period for  
its health plan, Employer makes an offer of minimum essential  
coverage providing minimum value to Employee and to  
Employee’s spouse and dependents. Employee elects to enroll  
in employee-only coverage starting January 1. On June 1,  
Employee experiences a reduction in hours that results in loss of  
eligibility for coverage under the plan. As of June 1, Employer  
terminates Employee’s existing coverage and makes an offer of  
COBRA continuation coverage to Employee, but does not make  
an offer to Employee’s spouse and dependents. Employer  
should enter code 1E (Minimum essential coverage providing  
minimum value offered to employee and at least minimum  
essential coverage offered to dependent(s) and spouse) on  
line 14 for months January–May, and should enter code 1B  
(Minimum essential coverage providing minimum value offered  
to employee only) on line 14 for months June–December.  
1F. Minimum essential coverage NOT providing minimum  
value offered to employee; employee and spouse or  
dependent(s); or employee, spouse, and dependents.  
1G. Offer of coverage for at least one month of the calendar  
year to an individual who was not an employee for any month of  
the calendar year or to an employee who was not a full-time  
employee for any month of the calendar year (which may include  
one or more months in which the individual was not an  
employee) and who enrolled in self-insured coverage for one or  
more months of the calendar year.  
Note. Code 1G applies for the entire year or not at all.  
Therefore, if code 1G applies, an ALE Member must enter code  
1G on line 14 in the “All 12 Months” column or in each separate  
monthly box (for all 12 months).  
Note. Notwithstanding the preceding instructions for completing  
line 14 of Form 1095-C, for purposes of section 4980H, an ALE  
Member is treated as having made an offer to the employee’s  
dependents for an entire plan year if the ALE Member provided  
the employee an effective opportunity to enroll the employee’s  
dependents at least once for the plan year, even if the employee  
declined to enroll the dependents in the coverage and, as a  
result, the dependents later did not receive an offer of COBRA  
coverage.  
Post-employment (non-COBRA) coverage. An offer of  
post-employment coverage to a former employee (or to that  
former employee’s spouse or dependent(s)) for coverage that  
would be effective after the employee has terminated  
employment (such as at retirement) should not be reported as an  
1H. No offer of coverage (employee not offered any health  
coverage or employee offered coverage that is not minimum  
essential coverage, which may include one or more months in  
which the individual was not an employee).  
1I. Reserved for future use.  
1J. Minimum essential coverage providing minimum value  
offered to employee and at least minimum essential coverage  
conditionally offered to spouse; minimum essential coverage not  
offered to dependent(s). (See Conditional offer of spousal  
coverage, earlier, for an additional description of conditional  
offers.)  
1K. Minimum essential coverage providing minimum value  
offered to employee; at least minimum essential coverage  
-11-  
Instructions for Forms 1094-C and 1095-C (2023)  
offered to dependents; and at least minimum essential coverage  
conditionally offered to spouse. (See Conditional offer of spousal  
coverage, earlier, for an additional description of conditional  
offers.)  
Line 16. For each calendar month, enter the applicable code, if  
any, from Code Series 2. Enter only one code from Code Series  
2 per calendar month. The instructions below address which  
code to use for a month if more than one code from Code Series  
2 could apply. If the same code applies for all 12 calendar  
months, you may enter the code in the “All 12 Months” box and  
not complete the monthly boxes. If none of the codes apply for a  
calendar month, leave the line blank for that month.  
1L. Individual coverage HRA offered to employee only with  
affordability determined by using employee’s primary residence  
location ZIP code.  
1M. Individual coverage HRA offered to employee and  
dependent(s) (not spouse) with affordability determined by using  
employee’s primary residence location ZIP code.  
Code Series 2—Section 4980H Safe Harbor Codes and  
Other Relief for ALE Members. An ALE Member enters the  
applicable Code Series 2 indicator code, if any, on line 16 to  
report for one or more months of the calendar year that one of  
the following situations applied to the employee.  
1N. Individual coverage HRA offered to employee, spouse,  
and dependent(s) with affordability determined by using  
employee’s primary residence location ZIP code.  
1O. Individual coverage HRA offered to employees only using  
The employee was not employed or was not a full-time  
the employee’s primary employment site ZIP code affordability  
safe harbor.  
employee,  
The employee enrolled in the minimum essential coverage  
1P. Individual coverage HRA offered to employee and  
offered,  
dependent(s) (not spouse) using the employee’s primary  
employment site ZIP code affordability safe harbor.  
The employee was in a Limited Non-Assessment Period with  
respect to section 4980H(b),  
1Q. Individual coverage HRA offered to employee, spouse,  
The ALE Member met one of the section 4980H affordability  
and dependent(s) using employee’s primary employment site  
ZIP code affordability safe harbor.  
safe harbors with respect to this employee, or  
The ALE Member was eligible for multiemployer interim rule  
1R. Individual coverage HRA that is NOT affordable offered to  
relief for this employee.  
employee; employee and spouse, or dependent(s); or employee,  
spouse, and dependents.  
If no indicator code applies, leave line 16 blank. In some  
circumstances, more than one indicator code could apply to the  
same employee in the same month. For example, an employee  
could be enrolled in health coverage for a particular month  
during which he or she is not a full-time employee. However, only  
one code may be used for a particular calendar month. For any  
month in which an employee enrolled in minimum essential  
coverage, in general, indicator code 2C reporting enrollment is  
used instead of any other indicator code that could also apply  
(but see the exceptions to this rule below regarding the  
multiemployer interim rule relief and enrollment in COBRA  
continuation coverage or other post-employment coverage). For  
an employee who did not enroll in health coverage, there are  
some specific ordering rules for which code to use. See the  
descriptions of the codes.  
1S. Individual coverage HRA offered to an individual who was  
not a full-time employee.  
1T. Individual coverage HRA offered to employee and spouse  
(not dependents) with affordability determined using employee's  
primary residence location ZIP code.  
1U. Individual coverage HRA offered to employee and spouse  
(not dependents) using employee's primary employment site ZIP  
code affordability safe harbor.  
1V. Reserved for future use.  
1W. Reserved for future use.  
1X. Reserved for future use.  
1Y. Reserved for future use.  
1Z. Reserved for future use.  
Line 15. Complete line 15 only if code 1B, 1C, 1D, 1E, 1J, 1K,  
1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is entered on line 14 either in  
the “All 12 Months” box or in any of the monthly boxes. Enter the  
amount of the Employee Required Contribution, which is,  
generally, the employee share of the monthly cost for the  
lowest-cost, self-only, minimum essential coverage providing  
minimum value that is offered to the employee. For additional  
details on how to determine the Employee Required  
Note. There is no code to enter on line 16 to indicate that a  
full-time employee offered coverage either did not enroll in the  
coverage or waived the coverage.  
2A. Employee not employed during the month. Enter code 2A  
if the employee was not employed on any day of the calendar  
month. Do not use code 2A for a month if the individual was an  
employee of the ALE Member on any day of the calendar month.  
Do not use code 2A for the month during which an employee  
terminates employment with the ALE Member.  
Contribution, including how to determine the Employee Required  
Contribution for the individual coverage HRA, see the Definitions  
section, later. Enter the amount, including any cents. If the  
employee is offered coverage but the Employee Required  
Contribution is zero, enter “0.00” (do not leave blank). If the  
Employee Required Contribution was the same amount for all 12  
calendar months, you may enter that monthly amount in the “All  
12 Months” box and not complete the monthly boxes. If the  
Employee Required Contribution was not the same for all 12  
months (for instance, if an ALE Member has a noncalendar year  
plan and the employee share of the premium changes with the  
new plan year that starts in 2023), enter the amount in each  
calendar month for which the employee was offered minimum  
value coverage. See the definition of Employee Required  
Contribution in the Definitions section, for more information,  
including on how to determine the monthly required contribution  
from annual data.  
2B. Employee not a full-time employee. Enter code 2B if the  
employee is not a full-time employee for the month and did not  
enroll in minimum essential coverage, if offered for the month.  
Enter code 2B also if the employee is a full-time employee for the  
month and whose offer of coverage (or coverage if the employee  
was enrolled) ended before the last day of the month solely  
because the employee terminated employment during the month  
(so that the offer of coverage or coverage would have continued  
if the employee had not terminated employment during the  
month).  
2C. Employee enrolled in health coverage offered. Enter code  
2C for any month in which the employee enrolled for each day of  
the month in health coverage offered by the ALE Member,  
regardless of whether any other code in Code Series 2 might  
also apply (for example, the code for a section 4980H  
affordability safe harbor) except as provided below. Do not enter  
code 2C on line 16 for any month in which the multiemployer  
interim rule relief applies (enter code 2E). Do not enter code 2C  
on line 16 if code 1G is entered on line 14. Do not enter code 2C  
on line 16 for any month in which a terminated employee is  
enrolled in COBRA continuation coverage or other  
For line 15, the amount entered might not be the amount  
the employee is paying for the coverage, for example, if  
the employee chose to enroll in more expensive  
TIP  
coverage, such as family coverage, or if the employee is eligible  
for certain other healthcare arrangements.  
-12-  
Instructions for Forms 1094-C and 1095-C (2023)  
 
post-employment coverage (enter code 2A). Do not enter code  
2C on line 16 for any month in which the employee enrolled in  
coverage that was not minimum essential coverage.  
of the employee’s primary site of employment if the ALE Member  
uses the work location safe harbor (code 1O, 1P, 1Q, or 1U).  
Location safe harbor for individual coverage HRAs. For  
purposes of section 4980H(b), an employer may use the cost of  
self-only coverage for the lowest cost silver plan for the  
employee for self-only coverage offered through the Exchange  
where the employee’s primary site of employment is located for  
determining whether an offer of an individual coverage HRA to a  
full-time employee is affordable. The ZIP code for the employee’s  
primary site of employment is used to identify the applicable  
lowest cost silver plan to determine affordability.  
2D. Employee in a section 4980H(b) Limited Non-Assessment  
Period. Enter code 2D for any month during which an employee  
is in a section 4980H(b) Limited Non-Assessment Period. If an  
employee is in an initial measurement period, enter code 2D  
(employee in a section 4980H(b) Limited Non-Assessment  
Period) for the month, and not code 2B (employee not a full-time  
employee). For an employee in a section 4980H(b) Limited  
Non-Assessment Period for whom the ALE Member is also  
eligible for the multiemployer interim rule relief for the month,  
enter code 2E (multiemployer interim rule relief) and not code 2D  
(employee in a section 4980H(b) Limited Non-Assessment  
Period).  
Part III—Covered Individuals (Lines 18–30)  
Note. If there are more than 13 covered individuals, additional  
copies of page 3, Part III, may be used.  
2E. Multiemployer interim rule relief. Enter code 2E for any  
Complete Part III ONLY if the ALE Member offers  
month for which the multiemployer arrangement interim  
guidance applies for that employee, regardless of whether any  
other code in Code Series 2 (including code 2C) might also  
apply. This relief is described under Offer of Health Coverage in  
the Definitions section of these instructions.  
employer-sponsored, self-insured health coverage, including an  
individual coverage HRA, in which the employee or other  
individual enrolled. For this purpose, employer-sponsored,  
self-insured health coverage does not include coverage under a  
multiemployer plan. Do not complete Part III if the ALE Member  
offers coverage only under an insured group health plan. If an  
ALE Member offers both insured and self-insured coverage,  
complete Part III only for employees who enroll in the  
self-insured coverage.  
Note. Although ALE Members may use the section 4980H  
affordability safe harbors to determine affordability for purposes  
of the multiemployer arrangement interim guidance, an ALE  
Member eligible for the relief provided in the multiemployer  
arrangement interim guidance for a month for an employee  
should enter code 2E (multiemployer interim rule relief), and not  
code 2F, 2G, or 2H (codes for section 4980H affordability safe  
harbors).  
An ALE Member with a self-insured major medical plan and a  
health reimbursement arrangement (HRA) that has an individual  
who enrolls in both types of minimum essential coverage is  
required to report the individual’s coverage under only one of the  
arrangements in Part III. An ALE Member with an insured major  
medical plan and an HRA that has an individual who enrolls in  
both types of minimum essential coverage is not required to  
report in Part III the HRA coverage of an individual if the  
2F. Section 4980H affordability Form W-2 safe harbor. Enter  
code 2F if the ALE Member used the section 4980H Form W-2  
safe harbor to determine affordability for purposes of section  
4980H(b) for this employee for the year. If an ALE Member uses  
this safe harbor for an employee, it must be used for all months  
of the calendar year for which the employee is offered health  
coverage.  
individual is eligible for the HRA because the individual enrolled  
in the insured major medical plan. An ALE Member with an HRA  
must report coverage under the HRA in Part III for any individual  
who is not enrolled in a major medical plan of the ALE Member  
(for example, if the individual is enrolled in a group health plan of  
another employer (such as spousal coverage) or if the ALE  
Member provides an individual coverage HRA). For additional  
information on the reporting of supplemental coverage, see  
Proposed Regulations section 1.6055-1(d)(2) and (3).  
2G. Section 4980H affordability federal poverty line safe  
harbor. Enter code 2G if the ALE Member used the section  
4980H federal poverty line safe harbor to determine affordability  
for purposes of section 4980H(b) for this employee for any  
month(s).  
2H. Section 4980H affordability rate of pay safe harbor. Enter  
code 2H if the ALE Member used the section 4980H rate of pay  
safe harbor to determine affordability for purposes of section  
4980H(b) for this employee for any month(s).  
If the ALE Member is completing Part III, enter “X” in the  
checkbox in Part III. If the ALE Member is not completing Part III,  
do not enter “X” in the checkbox in Part III.  
Note. An affordability safe harbor code should not be entered  
on line 16 for any month that the ALE Member did not offer  
minimum essential coverage, including an individual coverage  
HRA, to at least 95% of its full-time employees and their  
dependents (that is, any month for which the ALE Member  
checked the “No” box on Form 1094-C, Part III, column (a)). For  
more information, see the instructions for Form 1094-C, Part III,  
This part must be completed by an ALE Member offering  
self-insured health coverage for any individual who was an  
employee for one or more calendar months of the year, whether  
full-time or non-full-time, and who enrolled in the coverage. The  
employee (if enrolled in self-insured coverage) should be listed  
on line 18; any other family members who enrolled in coverage  
offered to the employee should be listed on subsequent lines.  
2I. Reserved for future use.  
All employee family members that are covered  
Note. References to 9.5% in the section 4980H affordability  
safe harbors and Qualifying Offer Method are applied based on  
the percentage as indexed for purposes of applying the  
affordability thresholds under section 36B (the premium tax  
credit). The percentage, as adjusted, is 9.61% for plan years  
beginning in 2022, and 9.12% for plan years beginning in 2023.  
individuals through the employee’s enrollment (for  
example, because the employee elected family  
TIP  
coverage) must be included on the same form as the employee  
(or any other individual to whom the offer was made). For  
example, if the employee is offered family coverage by his or her  
employer under a self-insured health plan and enrolls in the  
family coverage, the employee and the employee’s family  
members that are covered under the plan must all be reported  
on the same Form 1095-C.  
Line 17. If the ALE Member used code 1L, 1M, 1N, 1O, 1P, 1Q,  
1T, or 1U because it offered the employee an individual coverage  
HRA, enter the appropriate ZIP code used for identifying the  
lowest cost silver plan used to calculate the Employee Required  
Contribution in line 15. This will be the ZIP code of the  
If two or more employees employed by the same ALE  
Member are spouses or an employee and his or her dependent,  
and one employee enrolled in a coverage option under the plan  
that also covered the other employee(s) (for example, one  
employee’s residence (code 1L, 1M, 1N, or 1T) or the ZIP code  
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Instructions for Forms 1094-C and 1095-C (2023)  
 
employee spouse enrolled in family coverage that provided  
coverage to the other employee spouse and their employee  
dependent child), the enrollment information should be reflected  
only on Form 1095-C for the employee who enrolled in the  
coverage. (However, it would report the other employee family  
members as covered individuals.)  
employee listed in Part I, a taxpayer identification number (TIN),  
rather than an SSN, may be entered if the covered individual  
does not have an SSN, or the field may be left blank if the  
covered individual does not have a TIN.  
Column (c). Enter a date of birth (YYYY-MM-DD) for the  
covered individual only if column (b) is blank.  
Coverage of non-employee. This part may be completed by  
an ALE Member offering self-insured health coverage for any  
other individual who enrolled in the coverage under the plan for 1  
or more calendar months of the year but was not an employee  
for any calendar month of the year, such as a non-employee  
director, a retired employee who retired in a previous year, a  
terminated employee receiving COBRA continuation coverage  
(or any other form of post-employment coverage) who  
Column (d). Check this box if the individual was covered for at  
least one day per month for all 12 months of the calendar year.  
Column (e). If the individual was not covered for all 12 months  
of the calendar year, check the applicable box(es) for the  
month(s) in which the individual was covered for at least 1 day in  
the month.  
terminated employment during a previous year, and a  
Definitions  
non-employee COBRA beneficiary (but not including an  
individual who obtained coverage through the employee’s  
enrollment, such as a spouse or dependent obtaining coverage  
when an employee elects COBRA continuation coverage that is  
family coverage). If Form 1095-C is used with respect to an  
individual who was not an employee for any month of the  
calendar year, Part II must be completed by using code 1G in the  
“All 12 Months” box or the separate monthly boxes for all 12  
calendar months. The employer must report for these individuals  
using Form 1095-B, if it chooses not to use Form 1095-C.  
This section contains the definitions of key terms used in Forms  
1094-C and 1095-C and these instructions. For definitions of  
terms not included in this section, see the final regulations under  
section 4980H, T.D. 9655, 2014-9 I.R.B. 541, at IRS.gov/irb/  
2014-9_IRB/ar05.html and section 6056, T.D. 9661, 2014-13  
Affordability. Generally, the lowest cost silver plan for the  
employee based on the employee’s residence is used to  
determine affordability. The ZIP code for the employee’s  
residence is used to identify the applicable lowest cost silver  
plan to determine affordability.  
If a non-employee individual enrolls in the coverage  
under a self-insured health plan, all family members that  
are covered individuals because of the individual’s  
TIP  
Aggregated ALE Group. An Aggregated ALE Group refers to a  
group of ALE Members treated as a single employer under  
section 414(b), 414(c), 414(m), or 414(o). An ALE Member is a  
member of an Aggregated ALE Group for a month if it is treated  
as a single employer with the other members of the group on any  
day of the calendar month. If an ALE is made up of only one  
person or entity, that one ALE Member is not a part of an  
Aggregated ALE Group. Government entities and churches or  
conventions or associations of churches may apply a  
reasonable, good faith interpretation of the aggregation rules  
under section 414 in determining their status as an ALE or  
member of an Aggregated ALE Group. For more information on  
how the aggregation rules apply to government entity employers,  
see Notice 2015-87, Q&A 18, at IRS.gov/irb/2015-52_IRB/  
enrollment must be included on the same Form 1095-B or Form  
1095-C as the individual who is offered, and enrolls in, the  
coverage.  
Columns (a) through (e), as applicable, must be completed  
for each individual enrolled in the coverage, including the  
employee reported on line 1. Enter the 9-digit SSN or other TIN  
for each covered individual in column (b). Enter a date of birth in  
column (c) only if an SSN or other TIN is not entered in column  
(b). Column (d) will be checked if the individual was covered for  
at least 1 day in every month of the year. For individuals who  
were covered for some but not all months, information will be  
entered in column (e) indicating the months for which these  
individuals were covered.  
Governmental Unit employers offering self-insured  
Applicable Large Employer (ALE). An ALE is, for a particular  
calendar year, any single employer, or group of employers  
treated as an Aggregated ALE Group, that employed an average  
of at least 50 full-time employees (including full-time equivalent  
employees) on business days during the preceding calendar  
year. For purposes of determining an employer’s average  
number of employees, disregard an employee for any month in  
which the employee has coverage under a plan described in  
section 4980H(c)(2)(F) (generally, TRICARE or Veterans  
Administration coverage). A new employer (that is, an employer  
that was not in existence on any business day in the prior  
calendar year) is an ALE for the current calendar year if it  
reasonably expects to employ, and actually does employ, an  
average of at least 50 full-time employees (including full-time  
equivalent employees) on business days during the current  
calendar year. For information on a special rule for certain  
employers with seasonal workers, see the final regulations under  
section 4980H and FAQs on IRS.gov.  
health coverage that have delegated another  
TIP  
Governmental Unit (DGE) for purposes of reporting and  
furnishing enrollment information (meaning the information that  
otherwise would be reported on Form 1095-C, Part III), but have  
not designated a DGE for purposes of reporting and furnishing  
offer of coverage information (meaning the information that is  
reported on Form 1095-C, Part II), should file and furnish Forms  
1095-C with a completed Part I and Part II, but not a completed  
Part III, and should not check the box indicating that the  
Governmental Unit offers self-insured health coverage. In this  
case, the DGE should file Forms 1094-B and 1095-B to report  
enrollment information for employees on behalf of the  
Governmental Unit. See FAQs on IRS.gov.  
A DGE that has been delegated by a Governmental Unit for  
purposes of reporting and furnishing both offer of coverage and  
enrollment information (meaning the information that would be  
reported on Parts II and III of Form 1095-C) should file Forms  
1094-C and 1095-C to report the information for employees on  
behalf of the Governmental Unit.  
Applicable Large Employer Member (ALE Member). An  
ALE Member is a single person or entity that is an ALE, or if  
applicable, each person or entity that is a member of an  
Aggregated ALE Group. A person or entity that does not have  
employees or only has employees with no hours of service (for  
example, only employees whose entire service consists of work  
Column (a). Enter the name of each covered individual (first  
name, middle initial, last name), including the employee, if the  
employee is enrolled in self-insured coverage.  
Column (b). Enter the 9-digit SSN for each covered individual,  
including the dashes. For covered individuals who are not the  
-14-  
Instructions for Forms 1094-C and 1095-C (2023)  
 
outside of the United States that does not count as hours of  
service under section 4980H) is not an ALE Member.  
hours of service for two or more ALE Members of the same  
Aggregated ALE Group for the calendar month, those ALE  
Members must treat one of the ALE Members as the employer of  
that employee for that calendar month. See One Form 1095-C  
reporting in these circumstances. See Pub.15-A, Employer’s  
Supplemental Tax Guide, for more information on determining  
who is an employee.  
Note. In certain circumstances, an employee may have a  
break in service (including a break in service due to a  
termination of employment) during which the individual does not  
earn hours of service but, upon beginning to earn hours of  
service again, the ALE Member must treat the individual as a  
continuing employee rather than a new hire for purposes of  
certain rules under the regulations under section 4980H. See  
Regulations sections 54.4980H-3(c)(4) and 54.4980H-3(d)(6).  
These rules do not impact whether the individual was an  
employee during the break in service, so the individual should  
only be treated as an employee during the break in service for  
purposes of reporting if the individual remained an employee  
during that period (and had not terminated employment with the  
ALE Member). For example, an employee on unpaid leave  
during the break in service would be treated as an employee for  
reporting purposes during the break in service, while a former  
employee whose employment had been terminated during the  
break in service would not be treated as an employee for  
reporting purposes.  
Bona fide volunteer. A bona fide volunteer is an employee of a  
government entity or tax-exempt organization whose only  
compensation from that entity or organization is (1)  
reimbursement for (or reasonable allowance for) reasonable  
expenses incurred in the performance of services by volunteers,  
or (2) reasonable benefits (including length of service awards),  
and nominal fees, customarily paid by similar entities in  
connection with the performance of services by volunteers.  
COBRA continuation coverage. COBRA continuation  
coverage is health coverage that is required to be offered under  
the Consolidated Omnibus Budget Reconciliation Act of 1986  
(COBRA) in certain circumstances in which an employee or  
other individual covered under a health plan loses eligibility for  
coverage under that health plan (for example, because the  
employee terminates employment or has a reduction in hours).  
For purposes of these instructions, COBRA continuation  
coverage also includes coverage required under any other  
federal or state law that provides continuation coverage  
comparable to that provided under COBRA. For additional  
details, see section 4980B and Regulations sections 54.4980B-1  
through 54.4980B-10.  
Dependent. A dependent is an employee’s child, including a  
child who has been legally adopted or legally placed for adoption  
with the employee, who has not reached age 26. A child reaches  
age 26 on the 26th anniversary of the date the child was born  
and is treated as a dependent for the entire calendar month  
during which he or she reaches age 26. For this purpose, a  
dependent does not include stepchildren, foster children, or a  
child that does not reside in the United States (or a country  
contiguous to the United States) and who is not a United States  
citizen or national. For this purpose, a dependent does not  
include a spouse.  
Employee Required Contribution. The Employee Required  
Contribution is the employee’s share of the monthly cost for the  
lowest-cost, self-only minimum essential coverage providing  
minimum value that is offered to the employee by the ALE  
Member. The employee share is the portion of the monthly cost  
that would be paid by the employee for self-only coverage,  
whether paid through salary reduction or otherwise.  
For purposes of determining the amount of the employee’s  
share of the monthly cost, an ALE Member may divide the total  
cost to the employee for the plan year by the number of months  
in the plan year. This monthly amount of the employee’s share of  
the cost would then be reported for any months of that plan year  
that fall within the 2023 calendar year. For example, if the plan  
year begins January 1, the ALE Member may determine the  
amount to report for each month by taking the total annual  
employee cost for all 12 months and dividing by 12. If the plan  
year begins April 1, the ALE Member may determine the amount  
to report for January through March 2023, by taking the total  
annual employee cost for the plan year ending March 31, 2023,  
and dividing by 12 (and reporting that amount for January,  
February, and March 2023). Then, the ALE Member may  
determine the monthly amount for April through December 2023  
by taking the total annual employee cost for the plan year ending  
March 31, 2023, and dividing by 12 (and reporting that amount  
for April through December 2023).  
The Employee Required Contribution may not be the amount  
the employee paid for coverage. For additional rules on  
determining the amount of the Employee Required Contribution,  
including for cases in which an ALE Member makes available  
certain HRA contributions, cafeteria plan contributions, wellness  
program incentives, and opt-out payments, see Regulations  
sections 1.5000A-3(e)(3)(ii) and 1.36B-2(c)(3)(v)(A). Also see  
Notice 2015-87.  
Designated Governmental Entity (DGE). A DGE is a person  
or persons that are part of or related to the Governmental Unit  
that is the ALE Member and that is appropriately designated for  
purposes of these reporting requirements. For a Governmental  
Unit that has delegated some or all of its reporting  
responsibilities to a DGE for some or all of its employees, one  
Authoritative Transmittal must still be filed for that Governmental  
Unit reporting aggregate employer-level data for all employees of  
the Governmental Unit (including those for whom the  
Governmental Unit has delegated its reporting responsibilities).  
Eligible employer-sponsored plan. An eligible  
employer-sponsored plan refers to group health coverage for  
employees under (1) a governmental plan, such as the Federal  
Employees Health Benefits Program (FEHB); (2) an insured plan  
or coverage offered in the small or large group market within a  
state; (3) a grandfathered health plan offered in a group market;  
or (4) a self-insured group health plan for employees, including  
an individual coverage HRA.  
Employee. An employee is an individual who is an employee  
under the common-law standard for determining employer–  
employee relationships. An employee does not include a sole  
proprietor, a partner in a partnership, an S corporation  
shareholder who owns at least 2% of the S corporation, a leased  
employee within the meaning of section 414(n), or a worker that  
is a qualified real estate agent or direct seller.  
If an employee is an employee of more than one ALE Member  
of the same Aggregated ALE Group during a calendar month,  
the employee is treated as an employee of the ALE Member for  
whom the employee has the greatest number of hours of service  
for that calendar month; if the employee has an equal number of  
Special rules apply for individual coverage HRAs. Generally,  
the Employee Required Contribution for the individual coverage  
HRA means the required HRA contribution, as defined in  
Regulations section 1.36B-2(c)(5)(ii). However, for purposes of  
the individual coverage HRA safe harbors in Proposed  
Regulations section 54.4980H-5(f), the required contribution is  
determined based on the applicable lowest cost silver plan, as  
defined in Proposed Regulations 54.4980H-5(f)(7)(iii), and the  
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Instructions for Forms 1094-C and 1095-C (2023)  
       
monthly premium for the applicable lowest cost silver plan is  
determined based on the employee’s age, as defined in  
Proposed Regulations 54.4980H(f)(7)(i), and the employee’s  
applicable location, as defined in Proposed Regulations  
54.4980H(f)(7)(ii).  
For an employee offered an individual coverage HRA, the  
Employee Required Contribution is the excess of the monthly  
premium for the applicable lowest cost silver plan based on the  
employee’s applicable age over the monthly individual coverage  
HRA amount (generally, the annual individual coverage HRA  
amount divided by 12).  
Applicable lowest cost silver plan. Generally, the lowest  
cost silver plan for an employee for a calendar month is the  
lowest cost silver plan for self-only coverage of the employee  
offered through the Exchange for the ZIP code of the employee’s  
applicable location for the month. If there are different lowest  
cost silver plans in different parts of a rating area, an employee’s  
applicable lowest cost silver plan is the lowest cost silver plan in  
the part of the rating area in which the employee’s applicable  
location is located. The lowest cost silver plan for an employee is  
the lowest cost silver plan for the lowest age band in the  
individual market for the employee’s applicable location. For  
Applicable age. For an employee who is or will be eligible for  
an individual coverage HRA on the first day of the plan year, the  
employee’s applicable age for the plan year is the employee’s  
age on the first day of the plan year. For an employee who  
becomes eligible during the plan year, the employee’s applicable  
age for the remainder of the plan year is the employee’s age on  
the date the individual coverage HRA can first become effective  
for that employee. Note that for non-calendar year plans or for  
employees who become eligible during the plan year, the  
applicable age may not be the age reported in Part II of Form  
1095-C.  
period preceding that stability period. (The look-back  
measurement method for identifying full-time employees is  
available only for purposes of determining and computing liability  
under section 4980H, and not for purposes of determining if the  
employer is an Applicable Large Employer.) For purposes of  
both methods, 130 hours of service in a calendar month is  
treated as the monthly equivalent of at least 30 hours of service  
per week.  
An ALE Member must report complete information for all 12  
months of the calendar year for any of its employees who were  
full-time employees for one or more months of the calendar year.  
For more information on the identification of full-time employees,  
including discussion of the monthly measurement method and  
the look-back measurement method, and the rules for when an  
ALE Member may use one or both methods, see Regulations  
sections 54.4980H-1(a)(21) and 54.4980H-3, and Notice  
2014-49, 2014-41 I.R.B. 66 (describing a proposed approach to  
the application of the look-back measurement method in  
situations in which the measurement period applicable to an  
employee changes).  
Note. A former employee (for example, a retiree) is not a  
full-time employee for any month after termination of  
employment with the ALE Member. However, if the former  
employee was a full-time employee for any month of the  
calendar year (for example, before retiring mid-year), the ALE  
Member must complete information in Part II of Form 1095-C for  
all 12 months of the calendar year, using the appropriate codes.  
An ALE Member need not file a Form 1095-C for an  
individual who for each month of a calendar year is  
either not an employee of the ALE Member or is an  
TIP  
employee in a Limited Non-Assessment Period with respect to  
section 4980H(b). However, for the months in which the  
employee was an employee of the ALE Member, such an  
employee would be included in the total employee count  
reported on Form 1094-C, Part III, column (c). Also, if during the  
Limited Non-Assessment Period the employee enrolled in  
coverage under a self-insured, employer-sponsored plan, the  
ALE Member must file a Form 1095-C for the employee to report  
coverage information for the year.  
Applicable location. An employee’s applicable location is  
where the employee resides for the calendar month, or if the ALE  
Member is applying the location safe harbor, the employee’s  
primary site of employment for the calendar month.  
Employer. For purposes of these instructions, an employer is  
the person that is the employer of an employee under the  
common-law standard for determining employer–employee  
relationships and that is subject to the employer shared  
responsibility provisions of section 4980H (these employers are  
referred to as ALE Members). For more information on which  
employers are ALE Members, see the definitions of Applicable  
Large Employer (ALE) and Applicable Large Employer Member  
(ALE Member).  
Full-time equivalent employees. A combination of employees,  
each of whom individually is not treated as a full-time employee  
because he or she is not employed on average at least 30 hours  
of service per week with an employer, but who, in combination,  
are counted as the equivalent of a full-time employee solely for  
purposes of determining whether the employer is an ALE. For  
rules on how to determine full-time equivalent employees, see  
Regulations section 54.4980H-2(c).  
Governmental Unit and Agency or Instrumentality of a Gov-  
ernmental Unit. A Governmental Unit is the government of the  
United States, any state or political subdivision thereof, or any  
Indian tribal government (as defined in section 7701(a)(40)) or  
subdivision of an Indian tribal government (as defined in section  
7871(d)). For purposes of these instructions, references to a  
Governmental Unit include an Agency or Instrumentality of a  
Governmental Unit. Until guidance is issued that defines the  
term “Agency or Instrumentality of a Governmental Unit” for  
purposes of section 6056, an entity may determine whether it is  
an Agency or Instrumentality of a Governmental Unit based on a  
reasonable and good faith interpretation of existing rules relating  
to agency or instrumentality determinations for other federal tax  
purposes.  
Full-time employee. For purposes of Forms 1094-C and  
1095-C, the term “full-time employee” means a full-time  
employee, as defined under section 4980H and the related  
regulations, rather than any other definition of that term that the  
ALE Member may use for other purposes. Accordingly, a  
full-time employee is an employee who, for a calendar month, is  
determined to be a full-time employee under either the monthly  
measurement method or the look-back measurement method  
(as applicable to that employee). The monthly measurement  
method and the look-back measurement method are the two  
methods provided under the section 4980H regulations for  
determining whether an employee has sufficient hours of service  
to be a full-time employee. Under the monthly measurement  
method, a full-time employee is an employee who was employed  
an average of at least 30 hours of service per week with the ALE  
Member during a calendar month. Under the look-back  
Health coverage. As used in these instructions, health  
coverage refers to minimum essential coverage, unless  
otherwise indicated.  
measurement method, an employee is a full-time employee for  
each month of the stability period selected by the ALE Member if  
the employee was employed an average of at least 30 hours of  
service per week with the ALE Member during the measurement  
Hours of service. An hour of service is each hour for which an  
employee is paid, or entitled to payment, for the performance of  
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Instructions for Forms 1094-C and 1095-C (2023)  
     
duties for the employer, and each hour for which an employee is  
paid, or entitled to payment, for a period of time during which no  
duties are performed due to vacation, holiday, illness, incapacity  
(including disability), layoff, jury duty, military duty, or leave of  
absence. An hour of service does not include any hour of service  
performed as a bona fide volunteer of a government entity or  
tax-exempt entity, as part of a Federal Work-Study Program (or a  
substantially similar program of a state or political subdivision  
thereof) or to the extent the compensation for services  
determine whether a new employee is a full-time employee, and  
the employee is a variable hour employee, seasonal employee,  
or part-time employee, the initial measurement period for that  
employee and the administrative period immediately following  
the end of that initial measurement period.  
Period following change in status that occurs during initial  
measurement period under the look-back measurement method.  
If an ALE Member is using the look-back measurement method  
to determine whether a new employee is a full-time employee,  
and, as of the employee’s start date, the employee is a variable  
hour employee, seasonal employee, or part-time employee, but,  
during the initial measurement period, the employee has a  
change in employment status such that, if the employee had  
begun employment in the new position or status, the employee  
would have reasonably been expected to be a full-time  
employee, the period beginning on the date of the employee’s  
change in employment status and ending not later than the end  
of the third full calendar month following the change in  
performed constitutes income from sources outside the United  
States. For additional rules for determining hours of service, see  
Regulations sections 54.4980H-1(a)(24) and 54.4980H-3(b),  
and Notice 2015-87, Q&A 14, at IRS.gov/irb/2015-52_IRB/  
ar11.html. See section VI of the preamble to the section 4980H  
regulations for a discussion of determination of hours of service  
for categories of employees for whom the general rules for  
determining hours of service may present special difficulties  
(including adjunct faculty and commissioned salespeople) and  
certain categories of work hours associated with some positions  
of employment, including layover hours (for example, for certain  
airline employees), on-call hours, and work performed by an  
individual who is subject to a vow of poverty as a member of a  
religious order.  
employment status. If the employee is a full-time employee  
based on the initial measurement period and the associated  
stability period starts sooner than the end of the third full  
calendar month following the change in employment status, this  
Limited Non-Assessment Period ends on the day before the first  
day of that associated stability period.  
Individual coverage HRA. An HRA is a type of account-based  
health plan that employers can use to reimburse employees for  
their medical care expenses. An individual coverage HRA is an  
HRA integrated with individual health insurance coverage or  
Medicare, subject to certain conditions. For more information  
about individual coverage HRAs, see T.D. 9867 and IRS.gov/  
First calendar month of employment. If the employee’s first  
day of employment is a day other than the first day of the  
calendar month, then the employee’s first calendar month of  
employment is a Limited Non-Assessment Period.  
Minimum essential coverage (MEC). Although various types  
of health coverage may qualify as minimum essential coverage,  
for purposes of these instructions, minimum essential coverage  
refers to health coverage under an eligible employer-sponsored  
plan. An individual coverage HRA is a self-insured group health  
plan and an eligible employer sponsored plan. For more details  
on minimum essential coverage, see Minimum essential  
coverage in Pub. 974.  
Limited Non-Assessment Period. A Limited Non-Assessment  
Period generally refers to a period during which an ALE Member  
will not be subject to an assessable payment under section  
4980H(a) and, in certain cases, section 4980H(b), for a full-time  
employee, regardless of whether that employee is offered health  
coverage during that period.  
Minimum value. A plan provides minimum value if the plan  
pays at least 60% of the costs of benefits for a standard  
population and provides substantial coverage of in-patient  
hospitalization services and physician services. An individual  
coverage HRA that is affordable is treated as providing minimum  
value.  
The first five periods described below are Limited  
Non-Assessment Periods with respect to sections 4980H(a) and  
4980H(b) only if the employee is offered health coverage by the  
first day of the first month following the end of the period. Also,  
the first five periods described below are Limited  
Non-Assessment Periods for section 4980H(b) only if the health  
coverage that is offered at the end of the period provides  
minimum value. For more information on Limited  
Offer of health coverage. An ALE Member makes an offer of  
coverage to an employee if it provides the employee an effective  
opportunity to enroll in the health coverage (or to decline that  
coverage) at least once for each plan year. For this purpose, the  
plan year must be 12 consecutive months unless a short plan  
year of less than 12 consecutive months is permitted for a valid  
business purpose. An ALE Member makes an offer of health  
coverage to an employee for the plan year if it continues the  
employee’s election of coverage from a prior year but provides  
the employee an effective opportunity to opt out of the health  
coverage. If an ALE Member provides health coverage to an  
employee but does not provide the employee an effective  
opportunity to decline the coverage, the ALE Member is treated  
as having made an offer of health coverage to the employee only  
if that health coverage provides minimum value and does not  
have an Employee Required Contribution for the coverage for  
any calendar month of more than 9.5% (as adjusted) of a  
monthly amount determined as the mainland federal poverty line  
for a single individual for the applicable calendar year, divided by  
12.  
Non-Assessment Periods and the application of section 4980H,  
see Regulations section 54.4980H-1(a)(26).  
First year as ALE period. January through March of the first  
calendar year in which an employer is an ALE, but only for an  
employee who was not offered health coverage by the employer  
at any point during the prior calendar year.  
Waiting period under the monthly measurement method. If an  
ALE Member is using the monthly measurement method to  
determine whether an employee is a full-time employee, the  
period beginning with the first full calendar month in which the  
employee is first otherwise (but for completion of the waiting  
period) eligible for an offer of health coverage and ending no  
later than 2 full calendar months after the end of that first  
calendar month.  
Waiting period under the look-back measurement method. If  
an ALE Member is using the look-back measurement method to  
determine whether an employee is a full-time employee and the  
employee is reasonably expected to be a full-time employee at  
his or her start date, the period beginning on the employee’s  
start date and ending not later than the end of the employee’s  
third full calendar month of employment.  
For purposes of reporting, an offer to a spouse includes an  
offer to a spouse that is subject to one or more reasonable,  
objective conditions, regardless of whether the reasonable,  
objective conditions are satisfied. For example, an offer of  
coverage that is available to a spouse only if the spouse certifies  
that the spouse does not have access to health coverage from  
Initial measurement period and associated administrative  
period under the look-back measurement method. If an ALE  
Member is using the look-back measurement method to  
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Instructions for Forms 1094-C and 1095-C (2023)  
   
another employer is treated as an offer of coverage to the  
spouse for reporting purposes. Note that this treatment is for  
reporting purposes only, and will generally not affect the  
spouse’s eligibility for the premium tax credit if the spouse did  
not meet the condition and therefore did not have an actual offer  
of coverage. A conditional offer to a spouse is reported by  
entering code 1J or 1K (as applicable) on line 14 of Form  
1095-C. See the instructions for line 14 for more information. An  
offer to a dependent does not include an offer to a dependent  
that is subject to one or more reasonable, objective conditions  
unless the dependent satisfies the conditions and the dependent  
actually had an offer of coverage. In addition, an offer of  
coverage is treated as made to an employee’s dependents only  
if the offer of coverage is made to an unlimited number of  
dependents regardless of the actual number of dependents, if  
any, an employee has during any particular calendar month.  
An ALE Member offers health coverage for a month only if it  
offers health coverage that would provide coverage for every day  
of that calendar month. For reporting purposes, this means that  
an offer of coverage does not occur for a month if an employee’s  
employment terminates before the last day of a calendar month  
and the health coverage also ends before the last day of that  
calendar month (or for an employee who did not enroll in  
coverage, the coverage would have ended if the employee had  
enrolled in coverage). However, see the description of Code  
Series 2—Section 4980H Safe Harbor Codes and Other Relief  
for Employers, code 2B, which may be applicable in these  
circumstances to indicate that the ALE Member is treated as  
having offered coverage for the entire month for purposes of  
section 4980H.  
all calendar months during the calendar year for which the  
employee was a full-time employee for whom a section 4980H  
assessable payment could apply, with an Employee Required  
Contribution for each month, not exceeding 9.5 % (as adjusted)  
of the mainland single federal poverty line divided by 12,  
provided that the offer includes an offer of MEC to the  
employee’s spouse and dependents (if any).  
Privacy Act and Paperwork Reduction Act Notice. We ask  
for the information on these forms to carry out the Internal  
Revenue laws of the United States and the Patient Protection  
and Affordable Care Act. Our legal right to ask for the information  
on this form is Internal Revenue Code sections 6055, 6056,  
4980H, and their regulations. We request it to confirm that you  
are providing your employees offers of, and enrollment in, health  
coverage and to determine the employer shared responsibility  
payments and eligibility of your employees for premium tax  
credits. If you do not provide this information, we may be unable  
to determine whether your employees are entitled to premium  
tax credits. Providing false or fraudulent information may subject  
you to penalties. We may disclose this information to the  
Department of Justice for civil or criminal litigation and to cities,  
states, and the District of Columbia for use in administering their  
tax laws. We may also disclose this information to other  
countries under a tax treaty, to federal and state agencies to  
enforce federal nontax criminal laws, or to federal law  
enforcement and intelligence agencies to combat terrorism.  
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. Generally, tax returns and return  
An ALE Member offers health coverage to an employee if it,  
or another employer in the Aggregated ALE Group, or a third  
party, such as a multiemployer or single employer Taft-Hartley  
plan, a multiple employer welfare arrangement (MEWA), or, in  
certain cases, a staffing firm, offers health coverage on behalf of  
the employer. See Regulations sections 54.4980H-4(b)(2) and  
54.4980H-5(b).  
information are confidential, as required by section 6103.  
The time needed to complete and file this form will vary  
depending on individual circumstances. The estimated average  
time is:  
Interim Guidance Regarding Multiemployer  
Arrangements. An ALE Member is treated as offering  
health coverage to an employee if the ALE Member is  
TIP  
Form 1094-C. . . . . . . . . . . . . . . . . .  
Form 1095-C. . . . . . . . . . . . . . . . . .  
4 hr.  
required by a collective bargaining agreement or related  
participation agreement to make contributions for that employee  
to a multiemployer plan that offers, to individuals who satisfy the  
plan’s eligibility conditions, health coverage that is affordable and  
provides minimum value, and that also offers health coverage to  
those individuals’ dependents. For more information, see  
section XV.E of the preamble to the final regulations under  
section 4980H. This relief is referred to as the “multiemployer  
arrangement interim guidance” and the “multiemployer interim  
rule relief” in these instructions.  
12 min.  
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, Washington, DC 20224. Don't  
send the form to this office.  
Qualifying Offer. A Qualifying Offer is an offer of MEC  
providing minimum value to one or more full-time employees for  
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Instructions for Forms 1094-C and 1095-C (2023)