Fillable Form 1095-A

What is Form 1095-A?

Form 1095-A, officially the Health Insurance Marketplace Statement, is used to report certain information to the Internal Revenue Service (IRS) about individuals who enroll in a qualified health plan through the Health Insurance Marketplace.

Form 1095-A details your coverage. It contains information that is needed to help you validate the amount of advance payments of the premium tax credit (APTCs) you may have received. If you have not received APTCS, Form 1095-A may help to see if you are eligible to receive a premium tax credit.

You will use the information in this form to complete Form 8962 which will tell you if you need to adjust the amount of tax credits upward or downward.

The filing of this form is not your responsibility, you will use the form 1095-A furnished to you to file other forms. The information in this form is exclusively for your records and must be on hand before you complete your return. Filing your taxes before you obtain Form 1095-A can result in mistakes, and the IRS may send you a letter noting any discrepancies in your taxes.

Form 1095-A is not issued to consumers in Catastrophic plans, Medicaid plans, Child Health Plus, or the Essential Plan because they are not eligible for the Premium Tax Credit (PTC).

How to fill out Form 1095-A?

Part I — Recipient Information
Line 1. Enter where the recipient enrolled in coverage through the Marketplace.
Line 2. Enter the policy number assigned by the Marketplace.
Line 3. Enter the name of the company that issued the policy.
Line 4. Enter the name of the recipient of the statement.
Line 5. Enter the social security number (SSN) for the recipient shown on line 4.
Line 6. If the recipient does not have SSN, fill this in with the recipient's birth date.
Line 7. If the recipient has a spouse, enter the recipient’s spouse's name.
Line 8. Enter the recipient’s spouse's social security number (SSN).
Line 9. If the recipient’s spouse does not have SSN, fill this in with the recipient’s spouse's birth date.
Line 10. Enter the starting date of the policy.
Line 11. Enter the date of termination of the policy.
Lines 12–15. Enter the recipient’s address.

Part II—Covered Individuals
Lines 16a to 20a. Enter the name of each individual covered under the recipient’s policy.
Lines 16b to 20b. Provide the social security number (SSN) of each individual covered under the recipient’s policy.
Lines 16c to 20c. Provide the date of birth of each individual covered under the recipient’s policy.
Lines 16d to 20d. Provide the date the coverage started for each individual.
Lines 16e to 20e. Provide the date the coverage ended for each individual.

Part III—Coverage Information
Lines 21a to 32a. Enter the monthly enrollment premiums for the policy in which the covered individuals enrolled.
The premiums of separate health plans such as a dental plan with pediatric benefits should be entered here too. Nonessential benefits will be reduced in the amount to be entered here if there are nonessential benefits covered in your plan.
If the recipient failed to pay premiums for one or more months which resulted in termination, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.
Lines 21b to 32b. Enter the premiums for the applicable second lowest cost silver plan (SLCSP).
If the recipient failed to pay premiums for one or more months which resulted in termination, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.
Lines 21c to 32c. Enter the amount of advance credit payments for each month. If no advance credit payments were made, no information will be entered here.
Line 33a.Add the amounts entered on lines 21a to 32a.
Line 33b.Add the amounts entered on lines 21b to 32b.
Line 33c.Add the amounts entered on lines 21c to 32c.

Tips

• If you moved and have not informed your provider of your address change, your form may be forwarded by the U.S. Postal Service if you have a forwarding order in place. If there is no forwarding order, your form cannot be delivered.
• If you did not receive your Form 1095-A, you may access it from your online MyAccount on HealthCare.gov in the tax form section.
• If you do not have online access to MyAccount, then you can create an account on HealthCare.gov to view Form 1095-A. If you experience any issue when creating your online account or Form 1095-A is not posted in your online account, contact the Marketplace Call Center.
• If different members of your household had different health plans, you updated your coverage information during the year, or you switched plans during the year, you may receive more than one Form 1095-A.
• If you have more than one type of health insurance throughout the year, then you’ll get 1095-A forms from every provider who you had a Health Insurance Marketplace plan with.
• Like all tax documents, keep copies of Form 1095-A for at least three years.
• Besides Form 1095-A, it is possible that you will get other important tax forms. These are Forms 1095-B and 1095-C.
• Check the information on your Form 1095-A. If anything about your coverage or household is wrong, contact the Marketplace Call Center.
• If you filed your tax return based on information on your 1095-A form and you later get a corrected form, you may need to file an amended tax return.
• Complete all sections of IRS form 8962. Enter the enrollment premiums from Part III: Column A, line 33 (annual amount) and lines 21 to 32 (monthly amounts). Enter the second lowest cost Silver plan (SLCSP) premium from Part III: Column B, line 33 (annual amount) and lines 21 to 32 (monthly amounts). Enter the Advance payment of premium tax credit from Part III: Column C, line 33 (annual amount) and lines 21 to 32 (monthly amounts).