IRS Form 1095-B 2018 Health Coverage

IRS Form 1095-B is a U.S. Department of the Treasury - Internal Revenue Service - issued form also known as the "Health Coverage".

A PDF of the latest IRS Form 1095-B can be downloaded below or found on the U.S. Department of the Treasury - Internal Revenue Service Forms and Publications website.

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560118
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2018
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
(2018)
Cat. No. 60704B
560118
1095-B
VOID
OMB No. 1545-2252
Health Coverage
Form
2018
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
(2018)
Cat. No. 60704B
560216
2
Form 1095-B (2018)
Page
Instructions for Recipient
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.
This Form 1095-B provides information needed to report on your income tax
A. Small Business Health Options Program (SHOP)
return that the individuals in your tax family (yourself, spouse, and
B. Employer-sponsored coverage
dependents) had qualifying health coverage (referred to as “minimum
C. Government-sponsored program
essential coverage”) for some or all months during the year. Individuals who
D. Individual market insurance
don't have minimum essential coverage and don't qualify for an exemption
E . Multiemployer plan
from this requirement may be liable for the individual shared responsibility
F . Other designated minimum essential coverage
payment.
Minimum essential coverage includes government-sponsored programs,
If you or another family member received health insurance
eligible employer-sponsored plans, individual market plans, and other
TIP
coverage through a Health Insurance Marketplace (also known as
coverage the Department of Health and Human Services designates as
an Exchange), that coverage will generally be reported on a
minimum essential coverage. For more information on the requirement to
Form 1095-A rather than a Form 1095-B. If you or another family member
have minimum essential coverage and what is minimum essential coverage,
received employer-sponsored coverage, that coverage may be reported on a
see www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Individual-
Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
Shared-Responsibility-Provision.
www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-Health-
Providers of minimum essential coverage are required to furnish
Care-Information-Forms-for-Individuals.
TIP
only one Form 1095-B for all individuals whose coverage is
Line 9. Reserved.
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to other individuals covered under the policy if they
Part II. Information About Certain Employer-Sponsored Coverage, lines
10–15. If you had employer-sponsored health coverage, this part may
request it for their records.
provide information about the employer sponsoring the coverage. This part
Additional information. For additional information about the tax provisions
may show only the last four digits of the employer's EIN. This part also may
of the Affordable Care Act (ACA), including the individual shared
be left blank, even if you had employer-sponsored health coverage. If this
responsibility provisions, the premium tax credit, and the employer shared
part is blank, you do not need to fill in the information or return it to your
responsibility provisions, see www.irs.gov/Affordable-Care-Act/Individuals-
employer or other coverage provider.
and-Families or call the IRS Healthcare Hotline for ACA questions
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
(1-800-919-0452).
information about the coverage provider (insurance company, employer
Part I. Responsible Individual, lines 1–9. Part I reports information about
providing self-insured coverage, government agency sponsoring coverage
you and the coverage.
under a government program such as Medicaid or Medicare, or other
coverage sponsor). Line 18 reports a telephone number for the coverage
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
provider that you can call if you have questions about the information
taxpayer identification number (TIN), if applicable. For your protection, this
reported on the form.
form may show only the last four digits. However, the coverage provider is
required to report your complete SSN or other TIN, if applicable, to the IRS.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
Your date of birth will be entered on line 3 only if line 2 is blank.
or other TIN, and coverage information for each covered individual. A date of
birth will be entered in column (c) only if the SSN or other TIN isn't entered in
If you don't provide your SSN or other TIN and the SSNs or other TINs
!
column (b). Column (d) will be checked if the individual was covered for at
of all covered individuals to the sponsor of the coverage, the IRS may
least one day in every month of the year. For individuals who were covered
not be able to match the Form 1095-B with the individuals to
CAUTION
for some but not all months, information will be entered in column (e)
determine that they have complied with the individual shared responsibility
indicating the months for which these individuals were covered. If there are
provision.
more than six covered individuals, see Part IV, Continuation Sheet(s), for
information about the additional covered individuals.
560318
3
Form 1095-B (2018)
Page
Social security number (SSN) or other TIN
Date of birth (if SSN or other TIN is not available)
Name of responsible individual–First name, middle name, last name
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
(2018)

Download IRS Form 1095-B 2018 Health Coverage

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