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IRS 1095-A Template

The IRS 1095-A form is a document that provides information about health insurance coverage obtained through the Health Insurance Marketplace. It details the months you had coverage, the premiums paid, and any premium tax credits received. Understanding this form is essential for accurately filing your taxes and ensuring compliance with health care laws.

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The IRS 1095-A form plays a crucial role in the health insurance landscape, particularly for those who purchased coverage through the Health Insurance Marketplace. This form provides essential information about the insurance plan, including details about coverage, premium amounts, and any premium tax credits received. Taxpayers use the 1095-A to complete their federal tax returns, specifically to reconcile their premium tax credits. Understanding the information contained in this form is vital, as it affects tax liabilities and potential refunds. It is also important to ensure that the details on the form are accurate, as discrepancies can lead to complications during tax filing. With the tax season approaching, being well-informed about the 1095-A can help individuals navigate their tax responsibilities more efficiently.

Key takeaways

The IRS 1095-A form is essential for taxpayers who have enrolled in a health insurance plan through the Health Insurance Marketplace. Here are key takeaways regarding its use:

The form provides information about your health coverage, including the months you were covered and the amount of premium tax credits you received.
Taxpayers must receive a 1095-A from the Marketplace by January 31 each year.
This form is necessary for completing your federal tax return, particularly if you are claiming the Premium Tax Credit.
Review the form carefully for accuracy. Any discrepancies may affect your tax return.
If you find errors, contact the Marketplace to request a corrected form.
Keep a copy of the 1095-A with your tax records for at least three years.
Filing your taxes without this form may delay your refund or lead to complications with your tax return.

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Documents used along the form

The IRS 1095-A form is an important document that provides information about health coverage obtained through the Health Insurance Marketplace. However, it is often accompanied by other forms and documents that help clarify your tax situation and ensure compliance with health care requirements. Below is a list of six commonly used forms and documents that you may encounter alongside the 1095-A.

IRS Form 1040: This is the standard individual income tax return form used to report your annual income to the IRS. You will use information from the 1095-A when filling out this form to claim premium tax credits.
IRS Form 8962: This form is used to calculate the Premium Tax Credit (PTC) that you may be eligible for based on your income and family size. It requires information from your 1095-A to determine the amount of credit you can claim.
IRS Form 1095-B: This form is issued by health insurance providers to report minimum essential coverage. While it is not required for filing taxes, it can provide additional proof of health coverage during the year.
Texas Prenuptial Agreement Form: To secure your financial future, consider utilizing our comprehensive Texas Prenuptial Agreement document that outlines asset division and obligations before marriage.
IRS Form 1095-C: Employers with 50 or more full-time employees provide this form to report health coverage offered to employees. It helps verify whether you had access to affordable health insurance through your job.
Health Insurance Marketplace Statement: This document may accompany the 1095-A and provides additional details about your health coverage, including any changes that occurred during the year.
Proof of Income Documents: Documents such as W-2s, 1099s, or pay stubs may be necessary to verify your income when applying for premium tax credits and completing your tax return.

Understanding these documents can help you navigate your tax responsibilities more effectively. By gathering all relevant forms, including the 1095-A, you can ensure that you accurately report your health coverage and claim any credits you may be entitled to. This proactive approach can simplify the tax filing process and help you avoid potential issues down the line.

Dos and Don'ts

When filling out the IRS 1095-A form, it’s important to be careful and precise. Here are some guidelines to help you navigate the process.

Do: Verify your personal information, including your name and Social Security number, to ensure accuracy.
Do: Review the coverage details for each month to confirm that they match your health insurance records.
Do: Use the form to reconcile any premium tax credits you may be eligible for when filing your tax return.
Do: Keep a copy of the completed form for your records and for future reference.

Don't: Ignore any discrepancies. If something seems off, contact your health insurance provider for clarification.
Don't: Leave any fields blank. Fill out all required sections completely.
Don't: Submit the form without reviewing it for errors. Mistakes can delay your tax return processing.
Don't: Forget to file the 1095-A form with your tax return if you received health coverage through the Marketplace.

Common mistakes

Filling out the IRS 1095-A form can be a challenging task for many individuals. This form is essential for those who have health insurance through the Health Insurance Marketplace. However, several common mistakes can lead to confusion and potential issues with tax filings. Understanding these pitfalls can help ensure that the form is completed accurately.

One frequent error occurs when individuals fail to include all household members on the form. The 1095-A requires information for everyone in the household who was covered under the health plan. Omitting a family member can result in discrepancies when filing taxes, leading to delays or audits.

Another mistake is misreporting the premium amounts. The form includes details about the monthly premiums paid for coverage. If these amounts are recorded incorrectly, it can affect the calculation of the Premium Tax Credit. Always double-check the figures to ensure accuracy.

Additionally, some people overlook the importance of verifying the Marketplace identifier. Each health plan has a unique identifier that must be included on the 1095-A. Failing to provide the correct identifier can cause complications when reconciling the information with the IRS.

Many individuals also confuse the start and end dates of their coverage. It is crucial to accurately report the months during which coverage was active. Incorrect dates can lead to issues with eligibility for tax credits or the calculation of penalties for not having insurance.

Some filers make the mistake of not keeping a copy of the completed form. Retaining a copy is essential for personal records and can be invaluable if questions arise in the future. It’s a good practice to store this information securely for reference.

Moreover, failing to consult the instructions provided by the IRS can lead to errors. The IRS offers detailed guidance on how to fill out the form correctly. Ignoring these instructions can result in misinterpretations and mistakes that could have been easily avoided.

Lastly, individuals sometimes submit the form without reviewing it thoroughly. Taking the time to go over the completed form can catch errors before submission. A careful review can save time and prevent potential issues down the line.

File Characteristics

Fact Name	Description
Purpose	The IRS 1095-A form provides information about health insurance coverage obtained through the Health Insurance Marketplace.
Who Receives It	Individuals who enrolled in a health plan through the Marketplace will receive this form.
Reporting Year	The form is issued for each calendar year in which coverage was obtained.
Tax Filing Requirement	Taxpayers must use the information on the 1095-A to complete their federal tax returns, particularly when claiming premium tax credits.
Information Included	The form includes details such as the months of coverage, the premiums paid, and the amount of premium tax credit received.
Deadline for Issuance	The IRS requires that the 1095-A form be sent to recipients by January 31 of the year following the coverage year.
State-Specific Forms	Some states may have their own versions of the 1095 form, governed by state laws, such as California's AB 567.
Corrections	If there are errors on the 1095-A, individuals should contact the Marketplace to request a corrected form.
Importance for Tax Credits	The information on the 1095-A is crucial for determining eligibility for premium tax credits and reconciling them on tax returns.

Form Sample

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.

Form 1095-A

Department of the Treasury Internal Revenue Service

Health Insurance Marketplace Statement

▶ Do not attach to your tax return. Keep for your records.

▶Go to www.irs.gov/Form1095A for instructions and the latest information.

VOID

CORRECTED

OMB No. 1545-2232

2021

		Recipient Information
Part I		Recipient Information

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

A. Covered individual name

B. Covered individual SSN

C. Covered individual

D. Coverage start date

E. Coverage termination date

date of birth

Coverage Information

Part III

Month

A. Monthly enrollment premiums

B. Monthly second lowest cost silver

C. Monthly advance payment of

plan (SLCSP) premium

premium tax credit

January

February

March

April

May

June

July

August

September

October

November

December

Annual Totals

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60703Q

Form 1095-A (2021)

Page 2

Instructions for Recipient

You received this Form 1095-A because you or a family member enrolled in health insurance coverage through the Health Insurance Marketplace. This Form 1095-A provides information you need to complete Form 8962, Premium Tax Credit (PTC). You must complete

Form 8962 and file it with your tax return (Form 1040, Form

1040-SR, or Form 1040-NR) if any amount other than zero is shown in Part III, column C, of this Form 1095-A (meaning that you received premium assistance through advance payments of the premium tax credit (also called advance credit payments)) or if you want to take the premium tax credit. The filing requirement applies whether or not you’re otherwise required to file a tax return. If you are filing Form 8962, you cannot file Form 1040-NR-EZ, Form

1040-SS, or Form 1040-PR. The Marketplace has also reported the information on this form to the IRS. If you or your family members enrolled at the Marketplace in more than one qualified health plan policy, you will receive a Form 1095-A for each policy. Check the information on this form carefully. Please contact your Marketplace if you have questions concerning its accuracy. If you or your family members were enrolled in a Marketplace catastrophic health plan or separate dental policy, you aren’t entitled to take a premium tax credit 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 1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- Families/Health-Insurance-Marketplace-Statements.

Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the premium tax credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or call the IRS Healthcare Hotline for ACA questions (800-919-0452).

VOID box. If the “VOID” box is checked at the top of the form, you 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 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 Form 8962.

CORRECTED box. If the “CORRECTED” box is checked at the top of the form, use the information on this Form 1095-A to figure the premium tax credit and reconcile any advance credit payments on Form 8962. Don’t use the information on the original Form 1095-A you received for this policy.

Part I. Recipient Information, lines 1–15. Part I reports information about you, the insurance company that issued your policy, and the Marketplace where you enrolled in the coverage.

Line 1. This line identifies the state where you enrolled in coverage through the Marketplace.

Line 2. This line is the policy number assigned by the Marketplace to 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.

Line 3. This is the name of the insurance company that issued your policy.

Line 4. You are the recipient because you are the person the Marketplace identified at enrollment who is expected to file a tax return and who, if qualified, would take the premium tax credit for the year of coverage.

Line 5. This is your social security number (SSN). For your protection, this form may show only the last four digits. However, the Marketplace has reported your complete SSN to the IRS.

Line 6. A date of birth will be entered if there is no SSN on line 5.

Lines 7, 8, and 9. Information about your spouse will be entered only if advance credit payments were made for your coverage. The date of 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, SSN, 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.

If advance credit payments are made, the only individuals listed on Form 1095-A will be those whom you certified to the Marketplace would be in your tax family for the year of coverage (yourself, spouse, and dependents). If you certified to the Marketplace at enrollment that one or more of the individuals who enrolled in the plan aren’t individuals who would be in your tax family for the year of coverage, those individuals won’t be listed on your Form 1095-A. For example, if you indicated to the Marketplace at enrollment that an individual enrolling in the policy is your adult child who will not be your dependent for the year of coverage, that child will receive a separate Form 1095-A and won’t be listed in Part II on your Form 1095-A.

If advance credit payments are made and you certify that one or more enrolled individuals aren’t individuals who would be in your tax family for the year of coverage, your Form 1095-A will include coverage information in Part III that is applicable solely to the individuals listed on your Form 1095-A, and separately issued Forms 1095-A will include coverage information, including dollar amounts, applicable to those individuals not in your tax family.

If advance credit payments weren’t made and you didn’t identify at enrollment the individuals who would be in your tax family for the year of coverage, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A.

If there are more than 5 individuals covered by a policy, you will receive one or more additional Forms 1095-A that continue Part II.

Part III. Coverage Information, lines 21–33. Part III reports information about your insurance coverage that you will need to complete Form 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return.

Column A. This column is the monthly premiums for the plan in which you or family members were enrolled, including premiums that you paid and premiums that were paid through advance payments of the premium tax credit. If you or a family member enrolled in a separate dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered benefits that aren’t essential health benefits, such as adult dental or vision benefits, the amount in this column will be reduced by the premiums for the nonessential benefits. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.

Column B. This column is the monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined applies to members of your family enrolled in the coverage. The applicable SLCSP premium is used to compute your monthly advance credit payments and the premium tax credit you take on your return. See the instructions for Form 8962, Part II, on how to use the information in this column or how to complete Form 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for the months, regardless of whether advance credit payments were made for these months.

Column C. This column is the monthly amount of advance credit payments that were made to your insurance company on your behalf to pay for all or part of the premiums for your coverage. If this is the only column in Part III that is filled in with an amount other than zero for a month, it means your policy was terminated by your insurance company due to nonpayment of premiums, and you aren’t entitled to take the premium tax credit for that month when you file your tax return. You must still reconcile the entire advance payment that was paid on your behalf for that month using Form 8962. No information will be entered in this column if no advance credit payments were made.

Lines 21–33. The Marketplace will report the amounts in columns A, B, 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.