IRS Form 1095-A "Health Insurance Marketplace Statement"

What Is a Form 1095-A?

IRS Form 1095-A, Health Insurance Marketplace Statement, also known as the healthcare marketplace tax form, is a document used to report information to the Internal Revenue Service (IRS) about the individuals enrolled in a qualified health plan via the Health Insurance Marketplace. Health Insurance Marketplace is a platform where people without health care insurance can find necessary information about insurance options and alternatives and obtain health care insurance for themselves, their families, or businesses. Additionally, the health marketplace tax form is used to let the individuals coordinate and adjust the credit on their returns with advance credit payments, to help them claim the premium tax credit - a refundable credit that allows individuals and their families to pay for the premiums on their health insurance, and to complete and submit a correct tax return.

The latest version of the form was released by the IRS in 2019. Use this form to file your 2020 taxes. A fillable IRS Form 1095-A form is available for download below.

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Where Can I Get a 1095-A Form?

If you, your spouse or dependents are enrolled in the health insurance coverage, the Marketplace will send you this form; however, most individuals do not receive this form. Since the form is completed by the Marketplaces, individuals are not allowed to submit it, but you can use the information on the health marketplace tax form as guidance to aid you in filing an accurate tax return.

IRS Form 1095-A Instructions

  • You can use the information on the form to reconcile the premium tax credit with the advance payments, using Form 8962, Premium Tax Credit, that must be filed with your tax return;
  • It is possible to get a copy of the form online from your HealthCare account, if you bought coverage from the federally facilitated Marketplace;
  • You can find the form in your state-based Marketplace account if you bought coverage via a state-based Marketplace;
  • The form cannot be filed for a stand-alone dental plan or a catastrophic health plan;
  • If your policy covers more than five people, you will receive additional forms to list every individual;
  • If you have further questions, consult with the official instructions for the form issued by the IRS.

How to Fill out Form 1095-A?

  1. Part I - Recipient Information:
    • Submit the Marketplace identifier - a state name or an abbreviation;
    • Enter the number assigned to the policy by the Marketplace;
    • Write down the name of the policy issuer;
    • Identify the recipient of the statement using the full name. This must be the person identified as the tax filer at the time of enrollment. If the tax filer cannot be identified, enter the full name of the primary applicant for the health insurance coverage;
    • Write down the recipient's social security number; if you do not have that information, write down the date of birth;
    • If advance credit payments were made for the health insurance coverage, enter information about the recipient's spouse - the full name, the social security number, and the date of birth;
    • State the dates when the coverage under the policy began and when it was terminated;
    • Provide the address of the recipient.
  2. Part II - Covered Individuals. This section identifies all the people covered under the policy. State the covered individual's full name, the social security number or the date of birth, the starting and ending dates of coverage;
  3. Part III - Coverage Information. There are 12 lines for each month of the year. Enter the monthly enrollment premiums, monthly second lowest cost silver plan (one of the Health Insurance Marketplace «metal levels» that allows you to pay moderate monthly premiums and costs when you require care) premium, and monthly advance payment of premium tax credit.

Where to Send Form 1095-A?

Only electronic filing is available for IRS 1095-A Form. It does not exist in paper form and can only be filled out and submitted online. Health Insurance Marketplaces must submit the 1095-A statement through the Department of Health and Human Services Data Services Hub in order to report information on all enrollments in qualified health plans. IRS Form 1095-A due date is the last day of the first calendar month of the year. If the due date falls on a Saturday, Sunday, or a legal holiday, the statement must be submitted by the next business day. The annual report must be filed with the IRS on or before that date for coverage in the previous calendar year. The penalty for failing to provide this form to individuals or for providing incorrect forms is $250 for each document, the total annual amount of penalties cannot exceed $3,000,000.

IRS 1095-A Related Forms

IRS Form 1095-B, Health Coverage is a related document used to inform the IRS and the taxpayers about people that have minimum essential coverage (individual market plans, plans sponsored by eligible employers, and programs sponsored by the government) and consequently are not liable for the individual shared responsibility payment.

IRS Form 1095-C, Employer-Provided Health Insurance Offer and Coverage is a form used by the employers that have fifty or more full-time employees to send the required information about enrollment in health coverage and health coverage offers for these employees.

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Download IRS Form 1095-A "Health Insurance Marketplace Statement"

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CAUTION: NOT FOR FILING
Form 1095-A is provided here for informational purposes only.
Health Insurance Marketplaces use Form 1095-A to report information on
enrollments in a qualified health plan in the individual market through the
Marketplace. As the form is to be completed by the Marketplaces,
individuals cannot complete and use Form 1095-A available on IRS.gov.
Individuals receiving a completed Form 1095-A from the Health Insurance
Marketplace will use the information received on the form and the guidance
in the instructions to assist them in filing an accurate tax return.
CAUTION: NOT FOR FILING
Form 1095-A is provided here for informational purposes only.
Health Insurance Marketplaces use Form 1095-A to report information on
enrollments in a qualified health plan in the individual market through the
Marketplace. As the form is to be completed by the Marketplaces,
individuals cannot complete and use Form 1095-A available on IRS.gov.
Individuals receiving a completed Form 1095-A from the Health Insurance
Marketplace will use the information received on the form and the guidance
in the instructions to assist them in filing an accurate tax return.
1095-A
Health Insurance Marketplace Statement
VOID
OMB No. 1545-2232
Form
2019
Do not attach to your tax return. Keep for your records.
CORRECTED
Department of the Treasury
Go to www.irs.gov/Form1095A for instructions and the latest information.
Internal Revenue Service
Recipient Information
Part I
1 Marketplace identifier
2 Marketplace-assigned policy number
3 Policy issuer’s name
4 Recipient’s name
5 Recipient’s SSN
6 Recipient’s date of birth
7 Recipient’s spouse’s name
8 Recipient’s spouse’s SSN
9 Recipient’s spouse’s date of birth
10 Policy start date
11 Policy termination date
12 Street address (including apartment no.)
13 City or town
14 State or province
15 Country and ZIP or foreign postal code
Covered Individuals
Part II
C. Covered individual
A. Covered individual name
B. Covered individual SSN
D. Coverage start date
E. Coverage termination date
date of birth
16
17
18
19
20
Coverage Information
Part III
A. Monthly enrollment premiums
B. Monthly second lowest cost silver
C. Monthly advance payment of
Month
plan (SLCSP) premium
premium tax credit
21 January
22 February
23 March
24 April
25 May
26 June
27 July
28 August
29 September
30 October
31 November
32 December
33 Annual Totals
1095-A
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2019)
Cat. No. 60703Q
2
Form 1095-A (2019)
Page
Instructions for Recipient
If advance credit payments are made, the only individuals listed on
Form 1095-A will be those whom you certified to the Marketplace would
You received this Form 1095-A because you or a family member
be in your tax family for the year of coverage (yourself, spouse, and
enrolled in health insurance coverage through the Health Insurance
dependents). If you certified to the Marketplace at enrollment that one or
Marketplace. This Form 1095-A provides information you need to
more of the individuals who enrolled in the plan aren’t individuals who
complete Form 8962, Premium Tax Credit (PTC). You must complete
would be in your tax family for the year of coverage, those individuals
Form 8962 and file it with your tax return (Form 1040, Form
won’t be listed on your Form 1095-A. For example, if you indicated to
1040-SR, or Form 1040-NR) if any amount other than zero is shown
the Marketplace at enrollment that an individual enrolling in the policy is
in Part III, column C, of this Form 1095-A (meaning that you
your adult child who will not be your dependent for the year of coverage,
received premium assistance through advance payments of the
that child will receive a separate Form 1095-A and won’t be listed in
premium tax credit (also called advance credit payments)) or if you
Part II on your Form 1095-A.
want to take the premium tax credit. The filing requirement applies
If advance credit payments are made and you certify that one or more
whether or not you’re otherwise required to file a tax return. If you are
enrolled individuals aren’t individuals who would be in your tax family for
filing Form 8962, you cannot file Form 1040-NR-EZ, Form
the year of coverage, your Form 1095-A will include coverage
1040-SS, or Form 1040-PR. The Marketplace also has reported the
information in Part III that is applicable solely to the individuals listed on
information on this form to the IRS. If you or your family members
your Form 1095-A, and separately issued Forms 1095-A will include
enrolled at the Marketplace in more than one qualified health plan
coverage information, including dollar amounts, applicable to those
policy, you will receive a Form 1095-A for each policy. Check the
individuals not in your tax family.
information on this form carefully. Please contact your Marketplace if
If advance credit payments weren’t made and you didn’t identify at
you have questions concerning its accuracy. If you or your family
enrollment the individuals who would be in your tax family for the year of
members were enrolled in a Marketplace catastrophic health plan or
coverage, Form 1095-A will list all enrolled individuals in Part II on your
separate dental policy, you aren’t entitled to take a premium tax credit
Form 1095-A.
for this coverage when you file your return, even if you received a Form
1095-A for this coverage. For additional information related to Form
If there are more than 5 individuals covered by a policy, you will
1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and-
receive one or more additional Forms 1095-A that continue Part II.
Families/Health-Insurance-Marketplace-Statements.
Part III. Coverage Information, lines 21–33. Part III reports information
Additional information. For additional information about the tax
about your insurance coverage that you will need to complete Form
provisions of the Affordable Care Act (ACA), including the individual
8962 to reconcile advance credit payments or to take the premium tax
shared responsibility provisions and the premium tax credit, see
credit when you file your return.
www.irs.gov/Affordable-Care-Act/Individuals-and-Families or call the
Column A. This column is the monthly premiums for the plan in which
IRS Healthcare Hotline for ACA questions (800-919-0452).
you or family members were enrolled, including premiums that you paid
VOID box. If the “VOID” box is checked at the top of the form, you
and premiums that were paid through advance payments of the
premium tax credit. If you or a family member enrolled in a separate
previously received a Form 1095-A for the policy described in Part I.
That Form 1095-A was sent in error. You shouldn’t have received a
dental plan with pediatric benefits, this column includes the portion of
the dental plan premiums for the pediatric benefits. If your plan covered
Form 1095-A for this policy. Don’t use the information on this or the
previously received Form 1095-A to figure your premium tax credit on
benefits that aren’t essential health benefits, such as adult dental or
vision benefits, the amount in this column will be reduced by the
Form 8962.
premiums for the nonessential benefits. If the policy was terminated by
CORRECTED box. If the “CORRECTED” box is checked at the top of
your insurance company due to nonpayment of premiums for one or
the form, use the information on this Form 1095-A to figure the premium
more months, then a -0- will appear in this column for these months
tax credit and reconcile any advance credit payments on Form 8962.
regardless of whether advance credit payments were made for these
Don’t use the information on the original Form 1095-A you received for
months.
this policy.
Column B. This column is the monthly premium for the second lowest
Part I. Recipient Information, lines 1–15. Part I reports information
cost silver plan (SLCSP) that the Marketplace has determined applies to
about you, the insurance company that issued your policy, and the
members of your family enrolled in the coverage. The applicable SLCSP
Marketplace where you enrolled in the coverage.
premium is used to compute your monthly advance credit payments
Line 1. This line identifies the state where you enrolled in coverage
and the premium tax credit you take on your return. See the instructions
through the Marketplace.
for Form 8962, Part II, on how to use the information in this column or
Line 2. This line is the policy number assigned by the Marketplace to
how to complete Form 8962 if there is no information entered. If the
policy was terminated by your insurance company due to nonpayment
identify the policy in which you enrolled. If you are completing Part IV of
Form 8962, enter this number on line 30, 31, 32, or 33, box a.
of premiums for one or more months, then a -0- will appear in this
column for the months, regardless of whether advance credit payments
Line 3. This is the name of the insurance company that issued your
were made for these months.
policy.
Column C. This column is the monthly amount of advance credit
Line 4. You are the recipient because you are the person the
payments that were made to your insurance company on your behalf to
Marketplace identified at enrollment who is expected to file a tax return
pay for all or part of the premiums for your coverage. If this is the only
and who, if qualified, would take the premium tax credit for the year of
column in Part III that is filled in with an amount other than zero for a
coverage.
month, it means your policy was terminated by your insurance company
Line 5. This is your social security number. For your protection, this
due to nonpayment of premiums, and you aren’t entitled to take the
form may show only the last four digits. However, the Marketplace has
premium tax credit for that month when you file your tax return. You still
reported your complete social security number to the IRS.
must reconcile the entire advance payment that was paid on your behalf
Line 6. A date of birth will be entered if there is no social security
for that month using Form 8962. No information will be entered in this
column if no advance credit payments were made.
number on line 5.
Lines 7, 8, and 9. Information about your spouse will be entered only if
Lines 21–33. The Marketplace will report the amounts in columns A, B,
advance credit payments were made for your coverage. The date of
and C on lines 21–32 for each month and enter the totals on line 33. Use
this information to complete Form 8962, line 11 or lines 12–23.
birth will be entered on line 9 only if line 8 is blank.
Lines 10 and 11. These are the starting and ending dates of the policy.
Lines 12 through 15. Your address is entered on these lines.
Part II. Covered Individuals, lines 16–20. Part II reports information
about each individual who is covered under your policy. This information
includes the name, social security number, date of birth, and the starting
and ending dates of coverage for each covered individual. For each line,
a date of birth is reported in column C only if an SSN isn’t entered in
column B.
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