Fill in a Valid IRS 1095-C Template

The IRS 1095-C form is a crucial document that provides information regarding health insurance coverage offered by applicable large employers to their employees. This form serves both to comply with tax filing requirements and to demonstrate compliance with the Affordable Care Act. Understanding your responsibilities related to this form is essential for both employers and employees, so be sure to fill it out accurately by clicking the button below.

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The IRS 1095-C form plays a critical role in the landscape of health care and tax reporting in the United States, particularly for large employers. Employers with 50 or more full-time employees are required to provide this form, which details the health coverage offered to employees throughout the year. The 1095-C serves not only as a record of the health insurance benefits provided but also as an essential tool for employees during tax filing season. It includes important information such as the type of coverage offered, the months during which coverage was available, and employee details to ensure compliance with the Affordable Care Act (ACA). By accurately documenting this information, the form helps the IRS enforce health insurance mandates and aids employees in understanding their health coverage status. As such, familiarity with the 1095-C is vital for both employers and employees to navigate their rights and responsibilities under federal health care laws.

IRS 1095-C Example

600120

Form 1095-C

▶

VOID

Employer-Provided Health Insurance Offer and Coverage

OMB No. 1545-2251

Department of the Treasury

Do not attach to your tax return. Keep for your records.

CORRECTED

2020

Internal Revenue Service

▶ Go to www.irs.gov/Form1095C for instructions and the latest information.

Part I

Employee

Applicable Large Employer Member (Employer)

Name of employee (first name, middle initial, last name)

2 Social security number (SSN)

7 Name of employer

8 Employer identification number (EIN)

Street address (including apartment no.)

9 Street address (including room or suite no.)

10 Contact telephone number

City or town

5 State or province

6 Country and ZIP or foreign postal code

11 City or town

12 State or province

13 Country and ZIP or foreign postal code

Part II

Employee Offer of Coverage

Employee’s Age on January 1

Plan Start Month (enter 2-digit number):

All 12 Months

Jan

Feb

Mar

Apr

May

June

July

Aug

Sept

Oct

Nov

Dec

Offer of

Coverage (enter

required code)

Employee

Required

Contribution (see

instructions)

16 Section 4980H Safe Harbor and Other Relief (enter code, if applicable)

17 ZIP Code		Form 1095-C (2020)
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.	Cat. No. 60705M	Form 1095-C (2020)

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Form 1095-C (2020)

Page 2

Instructions for Recipient

You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provisions in the Affordable Care Act. This Form 1095-C includes information about the health insurance coverage offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large Employer, it is not required to furnish you a Form 1095-C providing information about the health coverage it offered.

In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as family members), enrolled in your employer’s health plan and that plan is a type of plan referred to as a “self-insured” plan, Form 1095-C, Part III, provides information about you and your family members who had certain health coverage (referred to as “minimum essential coverage”) for some or all months during the year. If you or your family members are eligible for certain types of minimum essential coverage, you may not be eligible for the premium tax credit.

If your employer provided you or a family member health coverage through an insured health plan or in another manner, you may receive information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual market plan, or miscellaneous coverage designated by the Department of Health and Human Services, you may receive information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, Health Insurance Marketplace Statement.

Employers are required to furnish Form 1095-C only to the employee. As the recipient of TIP this Form 1095-C, you should provide a copy to any family members covered under a

self-insured employer-sponsored plan listed in Part III if they request it for their records.

Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the individual shared responsibility provisions, the premium tax credit, and the employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for ACA questions (800-919-0452).

Part I. Employee

Lines 1–6. Part I, lines 1–6, reports information about you, the employee.

Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your SSN. However, the employer is required to report your complete SSN to the IRS.

Part I. Applicable Large Employer Member (Employer)

Lines 7–13. Part I, lines 7–13, reports information about your employer.

Line 10. This line includes a telephone number for the person whom you may call if you have questions about the information reported on the form or to report errors in the information on the form and ask that they be corrected.

Part II. Employer Offer of Coverage, Lines 14–17

Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and dependent(s), if any. (If you received an offer of coverage through a multiemployer plan due to your membership in a union, that offer may not be shown on line 14.) The information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.

1A. Minimum essential coverage providing minimum value offered to you with an employee required contribution for self-only coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states single federal poverty line and minimum essential coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.

1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to your spouse or dependent(s).

1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) but NOT your spouse.

1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your spouse but NOT your dependent(s).

1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) and spouse.

1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or you, your spouse, and dependent(s).

1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self- insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on line 14.

1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage).

1I. Reserved for future use.

1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to your spouse; and minimum essential coverage NOT offered to your dependent(s).

1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage conditionally offered to your spouse; and minimum essential coverage offered to your dependent(s).

1L. Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using employee’s primary residence location ZIP code.

1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee’s primary residence location ZIP code.

1N. Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee’s primary residence location ZIP code.

1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP code affordability safe harbor.

1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s primary employment site ZIP code affordability safe harbor.

1Q. Individual coverage HRA offered to you, spouse and dependent(s) using the employee’s primary employment site ZIP code affordability safe harbor.

1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.

1S. Individual coverage HRA offered to an individual who was not a full-time employee.

1T. Reserved for future use.

1U. Reserved for future use.

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.

(Continued on page 4)

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Form 1095-C (2020)

Page 3

Part III Covered Individuals

If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.

(a) Name of covered individual(s)

(b) SSN or other TIN (c) DOB (if SSN or other

(d) Covered

(e) Months of coverage

First name, middle initial, last name

TIN is not available)

all 12 months

Jan

Feb

Mar

Apr

May June July

Aug Sept

Oct

Nov

Dec

Form 1095-C (2020)

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Form 1095-C (2020)

Page 4

Instructions for Recipient (continued)

Line 15. This line reports the employee required contribution, which is the monthly cost to you for the lowest-cost self-only minimum essential coverage providing minimum value that your employer offered you. For an individual coverage HRA, the employee required contribution is the excess of the monthly premium based on the employee’s applicable age for the applicable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage HRA amount divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount reported on line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, or 1Q is entered on line 14. If you were offered coverage but there is no cost to you for the coverage, this line will report “0.00” for the amount. For more information, including on how your eligibility for other healthcare arrangements might affect the amount reported on line 15, visit IRS.gov.

Line 16. This code provides the IRS information to administer the employer shared responsibility provisions. Other than a code 2C, which reflects your enrollment in your employer’s coverage, none of this information affects your eligibility for the premium tax credit. For more information about the employer shared responsibility provisions, visit IRS.gov.

Line 17. This line reports the applicable ZIP code your employer used for determining affordability if you were offered an individual coverage HRA. If code 1L, 1M, or 1N was used on line 14, this will be your primary residence location. If code 1O, 1P, or 1Q was used on line 14, this will be your primary work location. For more information about individual coverage HRAs, visit IRS.gov.

Part III. Covered Individuals, Lines 18–30

Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage information about each individual (including any full-time employee and non-full-time employee, and any employee’s family members) covered under the employer’s health plan, if the plan is “self-insured.” A date of birth will be entered in column (c) only if an SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be checked if the individual was covered for at least one 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.

Click for IRS 1095-C File

File Breakdown

Fact Name	Description
Purpose of Form	The IRS 1095-C form provides information about health insurance coverage offered by an employer to its employees.
Who Receives It	Employees who worked for an Applicable Large Employer (ALE) during the year should receive this form.
Reporting Requirement	Employers with 50 or more full-time employees must file Form 1095-C to report health insurance coverage provided.
Deadline for Issuance	The form must be provided to employees by March 2 of the year following the year of reporting.
Tax Filing Inclusion	Employees do not need to attach Form 1095-C to their tax returns but should keep it for their records.
State-Specific Forms	Some states, like California and New Jersey, also require specific health coverage reporting forms under their laws.
Penalties for Non-Compliance	Failure to provide or file the 1095-C form correctly can result in penalties imposed by the IRS.
Information Included	The form includes details about the coverage offered, employee enrollment, and months of coverage.
Related Legislation	The Affordable Care Act (ACA) is the primary legislation governing the requirement for the 1095-C form.

Guide to Using IRS 1095-C

After completing the IRS 1095-C form, review it carefully for any errors. This form will be sent to the IRS and to the employees, so accuracy is essential. Below are the steps to fill out the form correctly.

Identify the correct tax year: Confirm that you are using the form for the right tax year.
Fill in your employer's information: Include the name, address, and Employer Identification Number (EIN) of the company.
Provide the employee’s details: Enter the employee's name, address, and Social Security Number (SSN).
Complete the offer of coverage section: Indicate whether health coverage was offered to the employee, and specify the months coverage was available.
Include information about the coverage: Detail the type of coverage offered and whether it was affordable according to IRS guidelines.
Sign and date the form: An authorized representative must sign and date the form before submission.

Get Answers on IRS 1095-C

What is the IRS 1095-C form?

The IRS 1095-C form is a document provided by applicable large employers (ALEs) to their employees. It details the health insurance coverage offered to employees, their spouses, and dependents during the year. This form is essential for employees to understand their health care options and determine if they are eligible for premium tax credits or if they need to pay a penalty for not having coverage.

Who receives a 1095-C form?

Any employee who works for an applicable large employer (i.e., generally those with 50 or more full-time employees) should receive a 1095-C form. This includes full-time employees, part-time employees, and sometimes those who were employed for a short period during the year. If you were employed by an ALE for any part of the year, expect to receive your form from that employer.

When should I expect to receive my 1095-C form?

Employers are required to send out the 1095-C form by March 2 of the year following the coverage year. For example, if you are looking for a 1095-C for the year 2023, it should arrive by March 2, 2024. It can be delivered by mail or electronically, depending on your employer's policy and your consent.

How do I use the information on the 1095-C form?

The information on the 1095-C form helps you when filing your federal tax return. You will need it to answer questions regarding health coverage on IRS Form 1040. Here’s how to use it:

Review the form to ensure all information is accurate.
Use the details about your health insurance coverage to determine if you met the ACA's mandate for coverage.
Check if you qualify for any premium tax credits or need to report any additional payments.

If you find discrepancies, contact your employer for corrections.

What should I do if I don't receive my 1095-C form?

If you haven't received your 1095-C form by early March, don't panic. First, check your email inbox and spam folder if you opted for electronic delivery. If you still can’t find it, reach out to your employer's HR or payroll department for assistance. They can confirm whether you were supposed to receive one and resend it if necessary.

Common mistakes

The IRS 1095-C form is an important document used to report health insurance coverage. However, people often make mistakes while filling it out, leading to potential issues with the IRS. Understanding these common errors can help ensure that the form is completed correctly.

One frequent mistake is failing to provide accurate personal information. It’s essential to double-check your name, address, and Social Security number for accuracy. An incorrect detail can cause delays in processing or even result in penalties.

Another common oversight involves the section detailing the coverage offered. Individuals should carefully indicate whether they were enrolled in health coverage for the entire year or just part of it. Incomplete or incorrect information in this area can lead to confusion regarding eligibility for certain health care programs.

In some cases, people forget to fill out all required sections. Each box on the form has specific instructions, and omitting vital information can be problematic. It’s crucial to read each section carefully and ensure nothing is skipped.

It's also a mistake to overlook the deadlines. The IRS expects the 1095-C form to be submitted by a specific date each year. Late submissions can trigger unwanted attention or penalties, so it's vital to keep track of these deadlines.

Some individuals incorrectly assume that their employer will automatically submit the form on their behalf. While employers do provide the form, employees should verify they receive it and check for accuracy. Missing the form can create complications when filing taxes.

Another issue can arise from confusion about the codes used on the form. Certain codes indicate whether coverage was offered and if the employee enrolled in it. Misinterpreting these codes can lead to incorrect reporting of health coverage.

Finally, a mistake often made is not keeping a copy of the submitted form. Maintaining a record can be helpful in case the IRS requires further information or clarification about your health coverage. Being organized can prevent headaches down the line.

Documents used along the form

The IRS 1095-C form plays a crucial role in reporting health coverage offered by applicable large employers (ALEs). However, it is often accompanied by other forms and documents that provide additional context and necessary information for individuals, businesses, and tax professionals. Here are some important documents commonly associated with the 1095-C:

IRS Form 1094-C: This transmittal form summarizes all the 1095-C forms submitted by an employer to the IRS. It serves as a cover letter and provides essential aggregate information about health coverage offered.
W-2 Form: The W-2 shows the income earned by an employee during the year and includes information about any health coverage provided. It's necessary for proper filing of income taxes.
Form 1095-A: Issued by the Health Insurance Marketplace, this form provides information about health coverage purchased from the marketplace, including premium amounts and subsidies received.
Form 8962: This is used to calculate the premium tax credit. Individuals will need this form if they received help paying for coverage through the Health Insurance Marketplace.
Form 8843: This form is often used by nonresident aliens to provide information about their days of presence in the U.S. It is particularly relevant for students and teachers in visa programs.
Form 1040: The standard U.S. individual income tax return. Taxpayers will report taxable income and claim deductions related to health insurance on this form.
Form 1095-B: This form provides information about the individual health insurance coverage that is minimum essential coverage. It's often used by smaller employers and government programs.
Health Coverage Exemption Form: Used to claim an exemption from the Affordable Care Act's requirement to maintain health insurance. This exception minimizes tax penalties for certain individuals.
Employer Shared Responsibility Payment (ESRP) Notice: A notification sent to employers regarding potential penalties for failing to comply with the ACA's employer mandate.
Plan Document: This document outlines the details of an employer's health insurance plan, including coverage specifics and eligibility criteria.

Understanding these documents can simplify tax filing processes and ensure compliance with health insurance reporting requirements. Each form plays a unique role, and having them readily available can prevent potential issues during tax season.

Similar forms

The IRS Form 1095-C is an important document related to health insurance coverage provided by certain employers. It helps individuals verify their health insurance status for tax purposes. Several other documents serve a similar purpose and provide crucial information regarding health insurance and coverage options. Below are four documents akin to the 1095-C form:

Form 1095-A: This form is used by anyone who purchased health coverage through the Health Insurance Marketplace. Like the 1095-C, it provides information about insurance coverage but specifically details premiums, and any financial assistance received.
Form 1095-B: This document is provided by health insurance carriers and shows the coverage that was in effect during the tax year. Similar to the 1095-C, it serves to confirm that the individual met the requirements under the Affordable Care Act for having health coverage.
Form W-2: While primarily a wage and tax statement, the W-2 form may also include information about the cost of health insurance coverage provided by an employer. It facilitates understanding the tax implications of employer-sponsored health plans, just like the 1095-C does.
Form 8962: This form is filed by individuals who are claiming the Premium Tax Credit. While it requires information from the 1095-A, it parallels the 1095-C in importance by ensuring that individuals receive appropriate tax credits for their health coverage, showing how these documents interconnect within the tax process.

Understanding these documents in relation to the 1095-C can help clarify the health insurance landscape and ensure compliance with federal regulations. Being informed is crucial for making appropriate health care decisions and handling tax responsibilities effectively.

Dos and Don'ts

When filling out the IRS 1095-C form, accuracy and attention to detail are essential. The following list highlights ten important dos and don'ts to keep in mind.

Do ensure that all employee information is current and accurate, including names and Social Security numbers.
Don't leave any required fields blank, as this could lead to delays or penalties.
Do check the coverage offer to make sure it aligns with the requirements for the Affordable Care Act.
Don't mix up the different parts of the form; each section serves a specific purpose.
Do keep a copy of the completed form for your records, as you may need it for future reference.
Don't submit the form electronically unless you're familiar with the online submission process.
Do review the form for any mathematical errors before finalizing it.
Don't forget to double-check dates related to coverage periods.
Do consult IRS guidelines if you're unsure about any section of the form.
Don't rush through the process; taking your time can help avoid mistakes.

Misconceptions

The IRS Form 1095-C is often misunderstood, leading to confusion for many individuals. Below are some common misconceptions about this important document:

Misconception 1: The 1095-C is a tax return form.

Many people believe that the 1095-C is a tax return that needs to be submitted during tax season. However, this form is not submitted with your tax return. Instead, it serves as a record of your health insurance coverage through your employer, specifically under the Affordable Care Act (ACA).

Misconception 2: Only large employers need to provide the 1095-C.

Some assume that only large employers, those with 50 or more full-time employees, are required to issue the 1095-C. While it is true that the requirement is primarily for these larger employers, some smaller businesses may also provide this form based on specific coverage circumstances. Therefore, it’s essential to know the details of your employer’s obligations.

Misconception 3: Receiving a 1095-C means you automatically qualify for health coverage.

Receiving this form does not guarantee that you are enrolled in health coverage. It simply reports what your employer offered you. You must actively enroll in the plan to have health insurance. Therefore, confirm your enrollment status separate from the information provided on the form.

Misconception 4: The 1095-C affects your tax refund.

Some individuals think that having a 1095-C form will directly influence the size of their tax refund. However, while this form does provide important information about your health coverage, it does not impact your refund amount. The crucial factor is whether you had qualifying health coverage for the entire year.

Key takeaways

The IRS 1095-C form is essential for individuals and employers alike, particularly when dealing with health care coverage. Here are some key takeaways:

Purpose of the Form: The 1095-C form provides information about the health care coverage offered by an employer to its employees. This document is required for tax purposes, as it indicates whether individuals met the health coverage requirements under the Affordable Care Act.
Who Receives It: Employers are responsible for issuing this form to employees who worked for them during the tax year. Employees should receive the form by early March of the following year.
Using the Information: When filing a tax return, individuals may need to reference the information on the 1095-C to determine if they qualify for premium tax credits or if they comply with the ACA’s individual mandate.
Verification and Accuracy: It is crucial to review the form carefully. Any discrepancies in the information provided could lead to issues during the tax filing process, so ensuring accuracy is paramount.