IRS Form 1095-C 2018 Employer-Provided Health Insurance Offer and Coverage

IRS Form 1095-C or the "Employer-provided Health Insurance Offer And Coverage" is a form issued by the U.S. Department of the Treasury - Internal Revenue Service.

A PDF of the latest IRS Form 1095-C 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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600118
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2018
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)
7 Name of employer
2 Social security number (SSN)
8 Employer identification number (EIN)
1 Name of employee
(f
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
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)
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
(d) Covered
(a) Name of covered individual(s)
(b) SSN or other TIN
(c) DOB (if SSN or other
all 12 months
TIN is not available)
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
First name, middle initial, last name
17
18
19
20
21
22
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2018)
Cat. No. 60705M
600118
VOID
1095-C
Employer-Provided Health Insurance Offer and Coverage
OMB No. 1545-2251
Form
2018
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)
7 Name of employer
2 Social security number (SSN)
8 Employer identification number (EIN)
1 Name of employee
(f
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
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)
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
(d) Covered
(a) Name of covered individual(s)
(b) SSN or other TIN
(c) DOB (if SSN or other
all 12 months
TIN is not available)
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
First name, middle initial, last name
17
18
19
20
21
22
1095-C
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Form
(2018)
Cat. No. 60705M
600216
2
Form 1095-C (2018)
Page
Instructions for Recipient
Part II. Employer Offer of Coverage, Lines 14–16
Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you
You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to
and your spouse and dependent(s), if any. (If you received an offer of coverage through a
the employer shared responsibility provision in the Affordable Care Act. This Form 1095-C includes
multiemployer plan due to your membership in a union, that offer may not be shown on line 14.) The
information about the health insurance coverage offered to you by your employer. Form 1095-C, Part
information on line 14 relates to eligibility for coverage subsidized by the premium tax credit for you,
II, includes information about the coverage, if any, your employer offered to you and your spouse and
your spouse, and dependent(s). For more information about the premium tax credit, see Pub. 974.
dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace
1A. Minimum essential coverage providing minimum value offered to you with an employee required
and wish to claim the premium tax credit, this information will assist you in determining whether you
contribution for self-only coverage equal to or less than 9.5% (as adjusted) of the 48 contiguous states
are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit
single federal poverty line and minimum essential coverage offered to your spouse and dependent(s)
(PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were
(referred to here as a Qualifying Offer). This code may be used to report for specific months for which a
Applicable Large Employers (for example, you left employment with one Applicable Large Employer
Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the
and began a new position of employment with another Applicable Large Employer). In that situation,
calendar year. For information on the adjustment of the 9.5%, see IRS.gov.
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
1B. Minimum essential coverage providing minimum value offered to you and minimum essential
coverage NOT offered to your spouse or dependent(s).
required to furnish you a Form 1095-C providing information about the health coverage it offered.
1C. Minimum essential coverage providing minimum value offered to you and minimum essential
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
coverage offered to your dependent(s) but NOT your spouse.
type of plan referred to as a "self-insured" plan, Form 1095-C, Part III, provides information to assist
1D. Minimum essential coverage providing minimum value offered to you and minimum essential
you in completing your income tax return by showing you or those family members had qualifying
coverage offered to your spouse but NOT your dependent(s).
health coverage (referred to as "minimum essential coverage") for some or all months during the year.
1E. Minimum essential coverage providing minimum value offered to you and minimum essential
If your employer provided you or a family member health coverage through an insured health plan or
coverage offered to your dependent(s) and spouse.
in another manner, the issuer of the insurance or the sponsor of the plan providing the coverage will
1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse
furnish you information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if
or dependent(s), or you, your spouse, and dependent(s).
you or a family member obtained minimum essential coverage from another source, such as a
1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-
government-sponsored program, an individual market plan, or miscellaneous coverage designated by
insured employer-sponsored coverage for one or more months of the calendar year. This code will be
the Department of Health and Human Services, the provider of that coverage will furnish you
entered in the All 12 Months box or in the separate monthly boxes for all 12 calendar months on
information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified
line 14.
health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report
1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that
information about that coverage on Form 1095-A, Health Insurance Marketplace Statement.
is NOT minimum essential coverage).
1I. Reserved.
Employers are required to furnish Form 1095-C only to the employee. As the recipient of
TIP
1J. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
this Form 1095-C, you should provide a copy to any family members covered under a
conditionally offered to your spouse; and minimum essential coverage NOT offered to your
self-insured employer-sponsored plan listed in Part III if they request it for their records.
dependent(s).
1K. Minimum essential coverage providing minimum value offered to you; minimum essential coverage
Additional information. For additional information about the tax provisions of the Affordable Care Act
conditionally offered to your spouse; and minimum essential coverage offered to your dependent(s).
(ACA), including the individual shared responsibility provisions, the premium tax credit, and the
employer shared responsibility provisions, see www.irs.gov/Affordable-Care-Act/Individuals-and-
Line 15. This line reports the employee required contribution, which is the monthly cost to you for the
Families or call the IRS Healthcare Hotline for ACA questions (1-800-919-0452).
lowest-cost self-only minimum essential coverage providing minimum value that your employer offered
you. The amount reported on line 15 may not be the amount you paid for coverage if, for example, you
Part I. Employee
chose to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only
Lines 1–6. Part I, lines 1–6, reports information about you, the employee.
if code 1B, 1C, 1D, 1E, 1J, or 1K is entered on line 14. If you were offered coverage but there is no cost
to you for the coverage, this line will report a “0.00” for the amount. For more information, including on
Line 2. This is your social security number (SSN). For your protection, this form may show only the last
how your eligibility for other healthcare arrangements might affect the amount reported on line 15, see
four digits of your SSN. However, the employer is required to report your complete SSN to the IRS.
IRS.gov.
If you do not provide your SSN and the SSNs of all covered individuals to the plan
!
Line 16. This code provides the IRS information to administer the employer shared responsibility
administrator, the IRS may not be able to match the Form 1095-C to determine that you
provisions. Other than a code 2C which reflects your enrollment in your employer's coverage, none of
and the other covered individuals have complied with the individual shared responsibility
this information affects your eligibility for the premium tax credit. For more information about the
provision. For covered individuals other than the employee listed in Part I, a Taxpayer
CAUTION
employer shared responsibility provisions, see IRS.gov.
Identification Number (TIN) may be provided instead of an SSN. See Part III.
Part III. Covered Individuals, Lines 17–22
Part I. Applicable Large Employer Member (Employer)
Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I),
Lines 7–13. Part I, lines 7–13, reports information about your employer.
and coverage information about each individual (including any full-time employee and non-full-time
Line 10. This line includes a telephone number for the person whom you may call if you have questions
employee, and any employee's family members) covered under the employer's health plan, if the plan
about the information reported on the form or to report errors in the information on the form and ask
is "self-insured." A date of birth will be entered in column (c) only if an SSN (or TIN for covered
that they be corrected.
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. If there are more than 6 covered individuals, see the
additional covered individuals on Part III, Continuation Sheet(s).
600318
3
Form 1095-C (2018)
Page
Social security number (SSN)
Name of employee
(f
irst name, middle initial, last name)
Part III
Covered Individuals — Continuation Sheet
(e) Months of Coverage
(a) Name of covered individual(s)
(c) DOB (if SSN or other
(d) Covered
(b) SSN or other TIN
all 12 months
TIN is not available)
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
First name, middle initial, last name
23
24
25
26
27
28
29
30
31
32
33
34
1095-C
Form
(2018)

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