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Форма 1095-А Інструкція

Інструкція по формуванню 1095-A , Заява на ринок медичного страхування

Реп. 2023

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Department of the Treasury  
Internal Revenue Service  
2023  
Instructions for Form 1095-A  
Health Insurance Marketplace Statement  
Section references are to the Internal Revenue Code  
unless otherwise noted.  
Statements to Individuals  
Furnishing required information to the individual.  
Marketplaces use Form 1095-A to furnish the required  
statement to recipients. A separate Form 1095-A must be  
furnished for each policy, and the information on the Form  
1095-A should relate only to that policy. If two or more tax  
filers are enrolled in one policy, each tax filer receives a  
statement reporting coverage of only the members of that  
tax filer's tax family (a tax family may include the tax filer,  
the tax filer’s spouse if the tax filer is filing a joint return  
with his or her spouse, and the tax filer’s dependents).  
See the instructions for line 4 for more information about  
who is a recipient. Don't furnish a Form 1095-A for a  
catastrophic health plan or a stand-alone dental plan. See  
the instructions for Part III, column A.  
Future Developments  
For the latest information about developments related to  
Form 1095-A and its instructions, such as legislation  
enacted after they were published, go to IRS.gov/  
Additional Information  
For information related to the Affordable Care Act, visit  
For additional information related to Form 1095-A, visit  
On Form 1095-A statements furnished to recipients,  
filers of Form 1095-A may truncate the social security  
number (SSN) of an individual receiving coverage by  
showing only the last four digits of the SSN and replacing  
the first five digits with asterisks (*) or Xs. Truncation isn't  
allowed on forms filed with the IRS.  
Statements must be furnished to recipients on paper by  
mail, unless a recipient affirmatively consents to receive  
the statement in an electronic format. If mailed, the  
statement must be sent to the recipient’s last known  
permanent address, or if no permanent address is known,  
to the recipient’s temporary address.  
General Instructions  
Purpose of Form  
Form 1095-A is used to report certain information to the  
IRS about individuals who enroll in a qualified health plan  
through the Health Insurance Marketplace. Form 1095-A  
is also furnished to individuals to allow them to take the  
premium tax credit, to reconcile the credit on their returns  
with advance payments of the premium tax credit  
(advance credit payments), and to file an accurate tax  
return.  
Consent to furnish statement electronically. The  
requirement to obtain affirmative consent to furnish a  
statement electronically ensures that statements are sent  
electronically only to individuals who are able to access  
them. A recipient may provide her or his consent on paper  
or electronically, such as by email. If consent is provided  
on paper, the recipient must confirm the consent  
electronically. An electronic statement may be furnished  
by email or by informing the recipient how to access the  
statement on a Marketplace’s website (for example, in the  
recipient's Marketplace account).  
Who Must File  
Health Insurance Marketplaces must file Form 1095-A to  
report information on all enrollments in qualified health  
plans in the individual market through the Marketplace. Do  
not file a Form 1095-A for a catastrophic health plan or a  
separate dental policy (called a stand-alone dental plan in  
these instructions).  
When To File  
File the annual report with the IRS and furnish the  
statements to individuals on or before January 31, 2024,  
for coverage in calendar year 2023.  
The requirement to furnish a statement to individuals  
will be met if the Form 1095-A is properly addressed and  
mailed or furnished electronically (if the recipient has  
consented to electronic receipt) on or before the due date.  
If the regular due date falls on a Saturday, Sunday, or legal  
holiday, furnish the statement by the next business day. A  
business day is any day that isn't a Saturday, Sunday, or  
legal holiday.  
Specific Instructions  
Part I—Recipient Information  
Line 1. Enter the Marketplace state name or  
abbreviation.  
Line 2. Enter the number the Marketplace assigned to  
the policy. If the policy number is greater than 15  
characters, enter only the last 15 characters.  
How To File  
Line 3. Enter the name of the issuer of the policy.  
Electronic filing. You must submit the information to the  
IRS electronically. Submit the information through the  
Department of Health and Human Services Data Services  
Hub.  
Line 4. Enter the name of the recipient of the statement.  
This should be the person identified at enrollment as the  
tax filer (the person who is expected to file a tax return, to  
Sep 29, 2023  
Cat. No. 63016Q  
claim other family members as dependents, and who, if  
qualified, would take the premium tax credit for the year of  
coverage for his or her tax family). If the tax filer can't be  
identified from the information provided at enrollment (for  
example, because no financial assistance was  
requested), enter the name of the primary applicant for the  
coverage.  
Column A. Enter the total monthly enrollment premiums  
for the policy in which the covered individuals enrolled.  
Include only the premiums allocable to essential health  
benefits. If a covered individual is enrolled in a  
stand-alone dental plan, include the portion of the  
premiums for the stand-alone dental plan that is allocable  
to pediatric dental coverage in the total monthly  
enrollment premiums. If more than one Form 1095-A is  
filed for coverage of the recipient’s family for the same  
months because, for example, a family member enrolled  
in a separate policy, include the portion of the premium for  
pediatric dental coverage in the amount in column A on  
only one Form 1095-A. If more than one tax filer is  
enrolled in a policy, report on each tax filer's Form 1095-A  
only those enrollment premiums allocated to that tax filer.  
If a policy is terminated by an issuer for nonpayment of  
premiums, enter -0- for a month in which the covered  
individuals have coverage but the premiums are not fully  
paid (generally, the first month of a grace period). If one or  
more covered individuals terminate coverage before the  
last day of a month, the amount reported in this column  
should not include any amount of the monthly enrollment  
premium that was refunded. If the issuer provided a  
premium credit for one or more months, the amount  
reported in this column should be the amount of the  
monthly enrollment premium as reduced by any premium  
credit.  
Line 5. Enter the social security number (SSN) for the  
recipient shown on line 4.  
Line 6. Enter the recipient’s date of birth only if line 5 is  
blank.  
Lines 7, 8, and 9. Enter information about the recipient’s  
spouse, if the recipient has one, if advance credit  
payments were made for the coverage. Enter this  
information even if the advance credit payments were not  
made for the spouse's coverage. Enter a date of birth only  
if line 8 is blank.  
Line 10. Enter the date that coverage under the policy  
started. If the policy was in effect at the start of the year,  
enter 1/1/2023.  
Line 11. Enter the date of termination if the policy was  
terminated during the year. If the policy was in effect at the  
end of the year, enter 12/31/2023.  
Lines 12–15. Enter the recipient's address.  
Part II—Covered Individuals  
Column B. Enter the premiums for the applicable second  
lowest cost silver plan (SLCSP) that was used as a  
benchmark to compute monthly advance credit payments.  
If advance payments were made, the applicable SLCSP  
for a month is the SLCSP that applies to individuals in Part  
II who were identified at enrollment as members of the tax  
filer's tax family (the tax filer, the tax filer's spouse if the tax  
filer is filing a joint return with her or his spouse, and any  
dependents of the tax filer) and who are enrolled in the  
coverage on the first day of the month and are not eligible  
for other health coverage for that month. However, if an  
individual enrolls in coverage and the enrollment is  
effective on the date of the individual's birth, adoption,  
placement in foster care, or on the effective date of a court  
order, the individual should be considered to have  
Enter on lines 16 through 20 and columns A through E  
information for each individual covered under the policy,  
including the recipient and the recipient's spouse, if  
covered. If advance credit payments were not made for  
any coverage under the policy and a tax family cannot be  
identified, enter in Part II information for all covered  
individuals. If advance credit payments were made for the  
coverage or a tax family can be identified, enter in Part II  
information only for covered individuals whom the tax filer  
certified at enrollment would be a part of the tax filer's tax  
family. Information about individuals enrolled in the same  
policy as the tax filer’s tax family who are not members of  
that tax family, including children, must be reported on a  
separate Form 1095-A.  
enrolled on the first day of the month for purposes of the  
applicable SLCSP premium reported in column B. If all  
covered individuals enroll after the first of the month, and  
no individual's coverage is effective on the date of the  
individual's birth, adoption, placement in foster care, or on  
the effective date of a court order, enter -0- in column B for  
that month. If more than one Form 1095-A is filed for  
coverage of a tax filer’s family for the same month (for  
example, because members of the family were split  
among several policies), enter the SLCSP premium that  
applies to all the family members who were enrolled in any  
policy on the first of the month and who were not eligible  
for other health coverage for that month. Enter this SLCSP  
premium in column B on each Form 1095-A.  
For each line, enter a date of birth in column C only if  
column B is blank. Enter in column D the date the  
coverage started for the individual. Enter in column E the  
date of termination if the individual's coverage was  
terminated during the year. If the coverage was in effect at  
the end of the year, enter 12/31/2023.  
If there are more than five covered individuals,  
complete one or more additional Forms 1095-A,  
Part II.  
TIP  
Part III—Coverage Information  
Enter information in Part III, lines 21 through 32, for each  
month of coverage. This information is determined on a  
monthly basis and may change during the year if there is a  
change in enrollment or other circumstances that affect  
eligibility for, or the amount of, the premium tax credit.  
Total the amounts on lines 21 through 32 and enter on  
line 33.  
In some cases, the information provided at enrollment  
may not indicate which covered individuals are members  
of the recipient's family and are not eligible for other health  
coverage. (Such information may not be provided, for  
example, because no financial assistance was  
requested.) If this is the case, and if the Marketplace has  
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Instructions for Form 1095-A (2023)  
provided a tool for determining the applicable SLCSP  
premium for the year of coverage at the time of filing the  
tax return, leave column B blank. If the Marketplace has  
not provided a tool for determining the applicable SLCSP  
premium, enter the premiums for the SLCSP that would  
apply to all individuals identified in Part II as covered for  
the month.  
If a policy is terminated by an issuer for nonpayment of  
premiums and advance credit payments are made,  
enter -0- for a month in which the covered individuals have  
coverage but the premiums are not paid (generally, the  
first month of a grace period). However, if an individual  
enrolled on the first day of a month terminates coverage  
before the last day of the month, the individual should be  
considered to have been enrolled for the entire month for  
purposes of the applicable SLCSP premium reported in  
column B.  
Column C. Enter the amount of advance credit payments  
for the month. If more than one Form 1095-A is filed for  
coverage of a tax filer’s family for the same months, enter  
only the advance credit payment amount allocated to the  
policy reported on this Form 1095-A. If the tax filer’s family  
is also enrolled in a stand-alone dental plan, any advance  
credit payments allocated to the stand-alone dental plan  
should be added to the advance credit payments  
allocated to one of the policies reported on a Form  
1095-A.  
discovering that information reported is incorrect. Check  
the CORRECTED box on the top of the form.  
Privacy Act and Paperwork Reduction Act Notice. We  
ask for the information on this form to carry out the Internal  
Revenue laws of the United States. You are required by  
the Internal Revenue Code to give us the information. We  
need it to ensure that taxpayers are complying with these  
laws and to allow us to figure and collect the right amount  
of tax.  
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 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:  
Preparing the form . . . . . . . . . . . .  
3 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.  
Void Statements  
If a Form 1095-A was sent for a policy that shouldn't be  
reported on a Form 1095-A, such as a stand-alone dental  
plan or a catastrophic health plan, send a duplicate of that  
Form 1095-A and check the VOID box at the top of the  
form. Provide this information to the IRS and to the  
recipient of the statement as soon as possible after  
discovering that the statement was sent in error.  
Correction to Information Reported  
Report corrected information on the Form 1095-A to the  
IRS and to the recipient as soon as possible after  
Instructions for Form 1095-A (2023)  
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