IRS Form 1095-B "Health Coverage"

What Is Form 1095-B?

IRS Form 1095-B, Health Coverage, is a document used to submit certain information to the Internal Revenue Service (IRS) and to taxpayers about individuals who have minimum essential coverage and are not liable for the individual shared responsibility payment. Minimum essential coverage means individual market plans, plans sponsored by eligible employers, and programs sponsored by the government.

Alternate Name:

  • IRS Health Coverage Form.

The latest version of the form was released by the IRS in 2021 with all previous editions obsolete. A fillable 1095-B form is available for download below. The Form 1095-B due date is the last day of February if you file it on paper and the last day of March if you file it electronically the year that follows the calendar year of coverage.

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What Is 1095-B Form Used for?

The 1095-B Tax Form is a health insurance statement that reports the type of health care coverage you have, the dependents covered by your insurance policy, and the period of coverage for the previous calendar year. It verifies that you and your dependents have minimum qualifying health insurance coverage. Having an IRS 1095-B Form in hand is proof that you have the coverage required by the Affordable Care Act.

What Is the Difference Between 1095-B and 1095-C?

Sometimes people who are covered by insurance from their employer receive a copy of a related form, which is very similar to 1095-B - 1095-C, Employer-Provided Health Insurance Offer and Coverage. It contains substantially the same information, but it is generated by employers with 50 or more full-time employees. It is possible that some taxpayers receive both tax forms, which depends on how the employers' coverage is set up.

IRS Form 1095-B Instructions

  1. You can send the form in a flat mailing. Do not paperclip or staple the forms together. You may send it in a package; however, bear in mind, that the IRS recommends filing the form electronically;
  2. The mailing addresses for the form are:
    • Department of the Treasury Internal Revenue Service Center Austin, TX 73301. Use this address for 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, and foreign countries;
    • Department of the Treasury Internal Revenue Service Center PO Box 219256 Kansas City, MO 64121-9256. Use this address for 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;
  3. There is a penalty of $270 for failure to submit a correct information return;
  4. Check out the IRS-provided instructions for more information on filing and submitting the form.

How to Fill out Form 1095-B?

  1. Part I, Responsible Individual. Provide information about the primary policyholder - the person who should receive the statement. Usually, it is a tax filer liable for the individual shared responsibility payment for the individuals covered. State this person's full name, social security number or date of birth, complete mailing address, and identify the origin of the health coverage. Consult with the separate instructions provided by the IRS to find out the responsible individual.
  2. Part II, Information About Certain Employer-Sponsored Coverage. Enter the name, employer identification number (EIN), and the complete mailing address of the employer who sponsors the coverage.
  3. Part III, Issuer or Other Coverage Provider. Enter the name, EIN, the complete mailing address, and the phone number of the coverage provider. It may be the carrier or issuer of insured coverage, the government agency that provided coverage, or a sponsor of a self-insured employer plan.
  4. Part IV, Covered Individuals. Provide the information on each individual covered - the full name, the social security number or the date of birth. State if the individual was covered for at least one day per month for all 12 months of the year. If not, check the boxes for the months in which the individual was covered. You can use the continuation sheet if there are more than six covered individuals.

IRS 1095-B Related Forms:

  • IRS Form 1094-B, Transmittal of Health Coverage Information Returns, is a form used by the IRS to obtain information about individuals that have health coverage meeting the standards of the Affordable Care Act;
  • IRS Form 1095-A, Health Insurance Marketplace Statement, is the main document in IRS Form 1095 Series and it is used to notify the IRS about the individuals that benefit from a qualified health plan acquired through the Health Insurance Marketplace. The health marketplace tax form is required to help people reconcile the credit on their returns with advance credit payments, to aid them in claiming the premium tax credit, and to complete a tax return without mistakes.
  • IRS Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, is a related form for the employers with 50 or more full-time employees that have to report to the IRS the information about health coverage and offers of health coverage required under sections 6055 and 6056 of the Internal Revenue Code.
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Download IRS Form 1095-B "Health Coverage"

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Page background image
560118
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2021
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Internal Revenue Service
Go to www.irs.gov/Form1095B for instructions and the latest information.
Part I
Responsible Individual
1
Name of responsible individual–First name, middle name, last name
2 Social security number (SSN) or other TIN
3 Date of birth (if SSN or other TIN is not available)
4 Street address (including apartment no.)
5
6
7
City or town
State or province
Country and ZIP or foreign postal code
9
Reserved
Enter letter identifying Origin of the Health Coverage (see instructions for codes):
.
.
.
8
Part II
Information About Certain Employer-Sponsored Coverage (see instructions)
10
Employer name
11
Employer identification number (EIN)
12 Street address (including room or suite no.)
13
City or town
14
State or province
15
Country and ZIP or foreign postal code
Part III
Issuer or Other Coverage Provider (see instructions)
16
Name
17
Employer identification number (EIN)
18
Contact telephone number
19 Street address (including room or suite no.)
20
City or town
21
State or province
22
Country and ZIP or foreign postal code
Part IV
Covered Individuals (Enter the information for each covered individual.)
(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
Jun
Jul
Aug
Sep
Oct
Nov
Dec
23
24
25
26
27
28
1095-B
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2021)
Cat. No. 60704B
560118
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2021
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Internal Revenue Service
Go to www.irs.gov/Form1095B for instructions and the latest information.
Part I
Responsible Individual
1
Name of responsible individual–First name, middle name, last name
2 Social security number (SSN) or other TIN
3 Date of birth (if SSN or other TIN is not available)
4 Street address (including apartment no.)
5
6
7
City or town
State or province
Country and ZIP or foreign postal code
9
Reserved
Enter letter identifying Origin of the Health Coverage (see instructions for codes):
.
.
.
8
Part II
Information About Certain Employer-Sponsored Coverage (see instructions)
10
Employer name
11
Employer identification number (EIN)
12 Street address (including room or suite no.)
13
City or town
14
State or province
15
Country and ZIP or foreign postal code
Part III
Issuer or Other Coverage Provider (see instructions)
16
Name
17
Employer identification number (EIN)
18
Contact telephone number
19 Street address (including room or suite no.)
20
City or town
21
State or province
22
Country and ZIP or foreign postal code
Part IV
Covered Individuals (Enter the information for each covered individual.)
(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
Jun
Jul
Aug
Sep
Oct
Nov
Dec
23
24
25
26
27
28
1095-B
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2021)
Cat. No. 60704B
560220
2
Form 1095-B (2021)
Page
Instructions for Recipient
If you or another family member received health insurance
TIP
coverage through a Health Insurance Marketplace (also known as
This Form 1095-B provides information about the individuals in your tax
an Exchange), that coverage will generally be reported on a
family (yourself, spouse, and dependents) who had certain health coverage
Form 1095-A rather than a Form 1095-B. If you or another family member
(referred to as “minimum essential coverage”) for some or all months during
received employer-sponsored coverage, that coverage may be reported on a
the year. Minimum essential coverage includes government-sponsored
Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
programs, eligible employer-sponsored plans, individual market plans,
and other coverage the Department of Health and Human Services
www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-
designates as minimum essential coverage.
Care-Information-Forms-for-Individuals.
Before 2019, individuals who did not have minimum essential coverage
Line 9. Reserved.
and did not qualify for an exemption from this requirement could be liable for
Part II. Information About Certain Employer-Sponsored Coverage, lines
the individual shared responsibility payment. Beginning in 2019, individuals
10–15. If you had employer-sponsored health coverage, this part may
will not be responsible for the individual shared responsibility payment
provide information about the employer sponsoring the coverage. This part
because the payment amount is reduced to $0. However, if individuals in
may show only the last four digits of the employer’s EIN. This part may also
your tax family are eligible for certain types of minimum essential coverage,
be left blank, even if you had employer-sponsored health coverage. If this
you may not be eligible for the premium tax credit. For more information on
part is blank, you do not need to fill in the information or return it to your
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).
employer or other coverage provider.
Providers of minimum essential coverage are required to furnish
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
TIP
only one Form 1095-B for all individuals whose coverage is
information about the coverage provider (insurance company, employer
reported on that form. As the recipient of this Form 1095-B, you
providing self-insured coverage, government agency sponsoring coverage
should provide a copy to other individuals covered under the policy if they
under a government program such as Medicaid or Medicare, or other
request it for their records.
coverage sponsor). Line 18 reports a telephone number for the coverage
provider that you can call if you have questions about the information
Additional information. For additional information about the tax provisions
reported on the form.
of the Affordable Care Act (ACA), including the individual shared
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
responsibility provisions, and the premium tax credit, see www.irs.gov/ACA
or other TIN, and coverage information for each covered individual. A date of
or call the IRS Healthcare Hotline for ACA questions (800-919-0452).
birth will be entered in column (c) only if the SSN or other TIN is not entered
Part I. Responsible Individual, lines 1–9. Part I reports information about
in column (b). Column (d) will be checked if the individual was covered for at
you and the coverage.
least 1 day in every month of the year. For individuals who were covered for
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
some but not all months, information will be entered in column (e) indicating
taxpayer identification number (TIN), if applicable. For your protection, this
the months for which these individuals were covered. If there are more than
form may show only the last four digits. However, the coverage provider is
six covered individuals, see Part IV, Continuation Sheet(s), for information
required to report your complete SSN or other TIN, if applicable, to the IRS.
about the additional covered individuals.
Your date of birth will be entered on line 3 only if line 2 is blank.
Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
A. Small Business Health Options Program (SHOP)
B. Employer-sponsored coverage
C. Government-sponsored program
D. Individual market insurance
E . Multiemployer plan
F . Other designated minimum essential coverage
G . Individual coverage health reimbursement arrangement (HRA)
560318
3
Form 1095-B (2021)
Page
Name of responsible individual–First name, middle name, last name
Social security number (SSN) or other TIN
Date of birth (if SSN or other TIN is not available)
Part IV
Covered Individuals — Continuation Sheet
(a) Name of covered individual(s)
(b) SSN or other TIN
(c) DOB (if SSN or other
(d) Covered
(e) Months of coverage
TIN is not available)
all 12 months
First name, middle initial, last name
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
29
30
31
32
33
34
35
36
37
38
39
40
1095-B
Form
(2021)
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