IRS Form 1095-C "Employer-Provided Health Insurance Offer and Coverage"

What Is Form 1095-C?

IRS Form 1095-C, Employer-Provided Health Insurance Offer and Coverage, is a document filed by employers with 50 or more full-time employees to inform the employees about health coverage and their current and prospective enrollment in insurance plans required under sections 6055 and 6056 of the Internal Revenue Code. This form is sent by the employer, not by the Internal Revenue Service (IRS), and it complements other health insurance disclosures - Form 1095-A and Form 1095-B.

Alternate Name:

  • Employer-Provided Health Insurance Tax Form

The latest version of the form was released in 2020 with all previous editions obsolete. A fillable Form 1095-C is available for download below.

The due day for Form 1095-C 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. There is a penalty of $270 for each return if you fail to provide an accurate information return.

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What Is Form 1095-C Used for?

The 1095-C tax return is sent to any employee of an Applicable Large Employers (ALE) member who qualifies as a full-time employee for at least one month of the calendar year. It is the ALE member's responsibility to report that information for every employee and to the IRS. Additionally, this form is used to determine the employees eligible for the premium tax credit.

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

Sometimes people who are covered by insurance from an employer receive a copy of a related form, which is very similar to 1095-C Form - 1095-B, Health Coverage. It contains substantially the same information, but it is generated by small self-funded groups or employers who use the Small Business Health Options Program (SHOP). It is possible that some taxpayers receive both tax forms, depending on how employers' coverage is set up.

IRS Form 1095-C Instructions

Check out the official IRS-issued instructions for Form 1095-C for more tips and information.

Mail completed forms to the Department of the Treasury Internal Revenue Service Center in Austin, Texas (if you live in 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) or to the Department of the Treasury Internal Revenue Service Center in Kansas City, Missouri (if you live in 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, or Wyoming).

If you must send 250 forms or more, you have to file electronically.

How to Fill out Form 1095-C?

  1. Part I - Employee. An employee means an individual who works as an employee under the common-law standard that outlines the employer-employee relationship. Provide the employee's full name, the social security number, and the complete address.
  2. Part I - Applicable Large Employer Member (Employer). This is a single employer, or a group of employers, that employed at least 50 full-time employees on business days throughout the calendar year to which the IRS 1095-C Form relates. Enter the employer's name, the employer identification number (EIN), the street address, and the telephone number.
  3. Part II - Employee Offer of Coverage. Use the box «Plan Start Month» to enter the two-digit number to state the calendar month during which the plan year begins for the employee who is offered coverage. Consult with the Instructions for the form to find the applicable codes for the Offer of Coverage and the section 4980H Safe Harbor and Other Relief (if applicable). State the amount of the employee required contribution.
  4. Part III - Covered Individuals. Columns a, b, c, d, and e must be completed for every individual enrolled in the health insurance coverage, including the employee identified in Part I of the form. State each individual's full name, the social security number or the date of birth, and indicate the months in which the individual was covered.

IRS 1095-C Related Forms:

  • IRS Form 1095-A, Health Insurance Marketplace Statement, is a related document used to inform the IRS about the individuals covered by a qualified health plan through the Health Insurance Marketplace. The health marketplace tax form is necessary to allow people to coordinate the credit on their returns with advance credit payments, to help them to claim the premium tax credit, and to complete a correct tax return.
  • IRS Form 1095-B, Health Coverage, is a related form used to provide certain information to the IRS and the taxpayers about people who have minimum essential coverage and therefore cannot have liability for the individual shared responsibility payment - a fine required under the Affordable Care Act that the individuals and their families who do not possess health insurance must pay jointly. Minimum essential coverage includes individual market plans, plans sponsored by eligible employers, and programs sponsored by the government.
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Rate (4.6 / 5) 122 votes
600120
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2020
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Go to www.irs.gov/Form1095C for instructions and the latest information.
Internal Revenue Service
Part I
Employee
Applicable Large Employer Member (Employer)
2 Social security number (SSN)
7 Name of employer
8 Employer identification number (EIN)
(f
1 Name of employee
irst name, middle initial, last name)
3 Street address (including apartment no.)
9 Street address (including room or suite no.)
10 Contact telephone number
4 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
14 Offer of
Coverage (enter
required code)
15 Employee
Required
Contribution (see
$
$
$
$
$
$
$
$
$
$
$
$
$
instructions)
16 Section 4980H
Safe Harbor and
Other Relief (enter
code, if applicable)
17 ZIP Code
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2020)
Cat. No. 60705M
600120
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2020
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Go to www.irs.gov/Form1095C for instructions and the latest information.
Internal Revenue Service
Part I
Employee
Applicable Large Employer Member (Employer)
2 Social security number (SSN)
7 Name of employer
8 Employer identification number (EIN)
(f
1 Name of employee
irst name, middle initial, last name)
3 Street address (including apartment no.)
9 Street address (including room or suite no.)
10 Contact telephone number
4 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
14 Offer of
Coverage (enter
required code)
15 Employee
Required
Contribution (see
$
$
$
$
$
$
$
$
$
$
$
$
$
instructions)
16 Section 4980H
Safe Harbor and
Other Relief (enter
code, if applicable)
17 ZIP Code
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2020)
Cat. No. 60705M
600220
2
Form 1095-C (2020)
Page
Instructions for Recipient
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
You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to
single federal poverty line and minimum essential coverage offered to your spouse and dependent(s)
the employer shared responsibility provisions in the Affordable Care Act. This Form 1095-C includes
(referred to here as a Qualifying Offer). This code may be used to report for specific months for which a
information about the health insurance coverage offered to you by your employer. Form 1095-C, Part
Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the
II, includes information about the coverage, if any, your employer offered to you and your spouse and
calendar year. For information on the adjustment of the 9.5%, visit IRS.gov.
dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace
1B. Minimum essential coverage providing minimum value offered to you and minimum essential
and wish to claim the premium tax credit, this information will assist you in determining whether you
coverage NOT offered to your spouse or dependent(s).
are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit
1C. Minimum essential coverage providing minimum value offered to you and minimum essential
(PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were
coverage offered to your dependent(s) but NOT your spouse.
Applicable Large Employers (for example, you left employment with one Applicable Large Employer
1D. Minimum essential coverage providing minimum value offered to you and minimum essential
and began a new position of employment with another Applicable Large Employer). In that situation,
coverage offered to your spouse but NOT your dependent(s).
each Form 1095-C would have information only about the health insurance coverage offered to you by
1E. Minimum essential coverage providing minimum value offered to you and minimum essential
the employer identified on the form. If your employer is not an Applicable Large Employer, it is not
coverage offered to your dependent(s) and spouse.
required to furnish you a Form 1095-C providing information about the health coverage it offered.
1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse
In addition, if you, or any other individual who is offered health coverage because of their relationship
or dependent(s), or you, your spouse, and dependent(s).
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
1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-
and your family members who had certain health coverage (referred to as “minimum essential
insured employer-sponsored coverage for one or more months of the calendar year. This code will be
coverage”) for some or all months during the year. If you or your family members are eligible for certain
entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on
types of minimum essential coverage, you may not be eligible for the premium tax credit.
line 14.
If your employer provided you or a family member health coverage through an insured health plan or
1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that
in another manner, you may receive information about the coverage separately on Form 1095-B,
is NOT minimum essential coverage).
Health Coverage. Similarly, if you or a family member obtained minimum essential coverage from
1I. Reserved for future use.
another source, such as a government-sponsored program, an individual market plan, or
1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
miscellaneous coverage designated by the Department of Health and Human Services, you may
conditionally offered to your spouse; and minimum essential coverage NOT offered to your
receive information about that coverage on Form 1095-B. If you or a family member enrolled in a
dependent(s).
qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will
1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
report information about that coverage on Form 1095-A, Health Insurance Marketplace Statement.
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
Employers are required to furnish Form 1095-C only to the employee. As the recipient of
TIP
determined by using employee’s primary residence location ZIP code.
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.
1M. Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability
determined by using employee’s primary residence location ZIP code.
Additional information. For additional information about the tax provisions of the Affordable Care Act
1N. Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by
(ACA), including the individual shared responsibility provisions, the premium tax credit, and the
using employee’s primary residence location ZIP code.
employer shared responsibility provisions, visit www.irs.gov/ACA or call the IRS Healthcare Hotline for
1O. Individual coverage HRA offered to you only using the employee’s primary employment site ZIP
ACA questions (800-919-0452).
code affordability safe harbor.
Part I. Employee
1P. Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee’s
primary employment site ZIP code affordability safe harbor.
Lines 1–6. Part I, lines 1–6, reports information about you, the employee.
1Q. Individual coverage HRA offered to you, spouse and dependent(s) using the employee’s primary
Line 2. This is your social security number (SSN). For your protection, this form may show only the last
employment site ZIP code affordability safe harbor.
four digits of your SSN. However, the employer is required to report your complete SSN to the IRS.
1R. Individual coverage HRA that is NOT affordable offered to you; employee and spouse or
Part I. Applicable Large Employer Member (Employer)
dependent(s); or employee, spouse, and dependents.
Lines 7–13. Part I, lines 7–13, reports information about your employer.
1S. Individual coverage HRA offered to an individual who was not a full-time employee.
Line 10. This line includes a telephone number for the person whom you may call if you have questions
1T. Reserved for future use.
about the information reported on the form or to report errors in the information on the form and ask
1U. Reserved for future use.
that they be corrected.
1V. Reserved for future use.
Part II. Employer Offer of Coverage, Lines 14–17
1W. Reserved for future use.
1X. Reserved for future use.
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
1Y. Reserved for future use.
multiemployer plan due to your membership in a union, that offer may not be shown on line 14.) The
1Z. Reserved for future use.
information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you,
(Continued on page 4)
your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.
600320
3
Form 1095-C (2020)
Page
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.
(e) Months of coverage
(a) Name of covered individual(s)
(b) SSN or other TIN
(c) DOB (if SSN or other
(d) Covered
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
18
19
20
21
22
23
24
25
26
27
28
29
30
1095-C
Form
(2020)
600420
4
Form 1095-C (2020)
Page
Instructions for Recipient (continued)
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
Line 15. This line reports the employee required contribution, which is the monthly cost to you for the
your primary residence location. If code 1O, 1P, or 1Q was used on line 14, this will be your primary
lowest-cost self-only minimum essential coverage providing minimum value that your employer offered
work location. For more information about individual coverage HRAs, visit IRS.gov.
you. For an individual coverage HRA, the employee required contribution is the excess of the monthly
Part III. Covered Individuals, Lines 18–30
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
Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I),
divided by 12). See the Instructions for Forms 1094-C and 1095-C for more details. The amount
and coverage information about each individual (including any full-time employee and non-full-time
reported on line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in
employee, and any employee’s family members) covered under the employer’s health plan, if the plan
more expensive coverage such as family coverage. Line 15 will show an amount only if code 1B, 1C,
is “self-insured.” A date of birth will be entered in column (c) only if an SSN (or TIN for covered
1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, or 1Q is entered on line 14. If you were offered coverage but there
individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be
is no cost to you for the coverage, this line will report “0.00” for the amount. For more information,
checked if the individual was covered for at least one day in every month of the year. For individuals
including on how your eligibility for other healthcare arrangements might affect the amount reported on
who were covered for some but not all months, information will be entered in column (e) indicating the
line 15, visit IRS.gov.
months for which these individuals were covered.
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.
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