Form 8963, Report of Health Insurance Provider Information

Userid: CPM

AH XSL/XML

Page 1 of 4

Schema:
Leadpct: 103% Pt. size: 10
instrx
Fileid: … ions/I8963/2013/A/XML/Cycle08/source

Draft

Ok to Print

(Init. & Date) _______

16:16 - 26-Nov-2013

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Instructions for Form 8963
(January 2014)

Department of the Treasury
Internal Revenue Service

Report of Health Insurance Provider Information
Section references are to the Internal
Revenue Code unless otherwise noted.

Future Developments

For the latest information and
developments related to Form 8963
and its instructions, such as
legislation enacted after they were
published, go to www.irs.gov/
form8963.

IRS e-file is the IRS’s electronic filing
program. For more information about
IRS e-file, visit IRS.gov. By filing
electronically, you will receive an
electronic acknowledgment once you
complete the transaction. Keep it with
your records.

Where To File

insured multiple employer welfare
arrangement (MEWA).
United States health risk. The
health risk of any individual who is (1)
a United States citizen, (2) a resident
of the United States (within the
meaning of section 7701(b)(1)(A)), or
(3) located in the United States, with
respect to the period such individual is
so located.
Health insurance. In general, the
term “health insurance” has the same
meaning as the term “health
insurance coverage” in section
9832(b)(1)(A), defined to mean
benefits consisting of medical care
(provided directly, through insurance
or reimbursement, or otherwise)
under any hospital or medical service
policy or certificate, hospital or
medical service plan contract, or
health maintenance organization
contract offered by a covered entity.
The term “health insurance” includes
limited scope (also called
stand-alone) dental and vision
benefits under section 9832(c)(2)(A)
and retiree-only health insurance.
For the definitions of controlled
group, single-person covered entity
and designated entity, see Specific
Instructions next.

D U te
R s
r
e
A
01 F O na
T
/0
nl l
2/ AS y
20
O
14 F

General Instructions

E-File: It’s Convenient, Safe and
Secure

Purpose of Form

File Form 8963 to report net premiums
written for health insurance of United
States health risks. The information
you report will be used by the IRS to
calculate the annual fee on health
insurance providers.

In

The fee is imposed by Public Law
111-148, Patient Protection and
Affordable Care Act (PPACA) section
9010, as amended by PPACA section
10905, and as further amended by
Public Law 111-152, Health Care and
Education Reconciliation Act of 2010
section 1406 (collectively the “ACA”).

Who Must File

Generally, a covered entity that
provides health insurance for any
United States health risk during the
2014 fee year (the calendar year in
which the fee must be paid) must file a
Form 8963.

When To File

File Form 8963 by April 15, 2014, for
2013 calendar year net premiums
written information (2013 is the data
year, which is the calendar year
immediately before the fee year).

How To File

There are two ways to file your Form
8963:
1. You can file Form 8963 (with
Form 8453-R, Declaration and
Signature for Electronic Filing of
Forms 8947 and 8963) electronically
by accessing IRS e-file using your
own computer, or
2. You can file a paper Form 8963.

Nov 26, 2013

If you are not filing
electronically, send your
paper Form 8963 to the
following address.
Department of Treasury
Internal Revenue Service
1973 Rulon White Boulevard
Mail Stop 4916 IPF
Ogden, UT 84404

Public Disclosure

The information on this form is not
confidential. Although, generally, tax
returns and return information are
confidential, as required by section
6103, pursuant to PPACA section
9010, as amended, the information on
this form is not subject to section
6103. All information on this form is
subject to public disclosure. Do not
include personal information other
than that requested on this form.

Definitions

Covered entity. Generally, covered
entity means any entity with net
premiums written for health insurance
for United States health risks during
the fee year that is (1) a health
insurance issuer within the meaning of
section 9832(b)(2); (2) a health
maintenance organization within the
meaning of section 9832(b)(3); (3) an
insurance company that is subject to
tax under subchapter L, Part I or II, or
that would be subject to tax under
subchapter L, Part I or II, but for the
entity being exempt from tax under
section 501(a); (4) an insurer that
provides health insurance under
Medicare Advantage, Medicare Part
D, or Medicaid; or (5) a non-fully
Cat. No. 37785K

Specific Instructions

Covered entity information. A
covered entity is either a
single-person covered entity or a
member of a controlled group. A
single-person covered entity is a
covered entity that is not a member of
a controlled group. Under the
controlled group rule of ACA section
9010(c)(3), all persons treated as a
single employer under sections 52(a),
52(b), 414(m), or 414(o) will be
treated as one covered entity. In
applying the single employer rules,
ACA section 9010(c)(3)(B) provides
that a foreign entity subject to tax
under section 881 is included within a
controlled group under section 52(a)
or 52(b). A covered entity is treated as
being a member of a controlled group

Page 2 of 4

Fileid: … ions/I8963/2013/A/XML/Cycle08/source

16:16 - 26-Nov-2013

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

if it is a member of the group at the
end of the day on December 31,
2013.
Box 1. Check box 1 if you are a
single-person covered entity. You
must sign Part I on page 1 (see Part l
signature instructions below). Also
complete the first line of Schedule A.

Correction. Check the box if this is a
corrected report.
Employer identification number
(EIN). Enter your EIN. If you do not
have an EIN, you must apply for one.
If filing your Form 8963 electronically,
enter your 9-digit EIN without the
dash. The EIN will be properly
formatted for you.

Part I. Signature of Official
Signing on Behalf of the
Single-Person Covered Entity
or Designated Entity (Agent of
an Affiliated Group, or Other
Designated Entity) and Consent
by the Designated Entity (if
applicable)
Complete the date signed, phone
number, fax number, the typed name
of the signing official, and the title of
the signing official. If you are filing by
paper, you may sign this form
manually.

If you file Form 8963 electronically,
you will need to manually sign, scan,
and upload Form 8453-R (see Form
8453-R) with this form.

In

D U te
R s
r
e
A
01 F O na
T
/0
nl l
2/ AS y
20
O
14 F

Designated entity. Each controlled
group must have a designated entity.
If the controlled group, without
regard to foreign corporations
included under ACA section 9010(c)
(3)(B), is also an affiliated group that
files a consolidated return for federal
income tax purposes, the designated
entity is the agent of the affiliated
group as identified on the tax return
filed for the data year.
If not, the controlled group must
select one of its members to be the
designated entity.
If a controlled group does not
select a designated entity, the IRS will
select a member of the controlled
group as the designated entity for the
controlled group.
The designated entity is
responsible for the following for the
group:
Filing Form 8963,
Receiving IRS communications
about the fee,
Filing any necessary error
correction report,
Paying the fee to the IRS,
Obtaining consents from all
controlled group members that are
required to be listed on Schedule A of
this form, and
Providing (to the IRS upon request)
the consents obtained from controlled
group members that are required to
be listed on Schedule A of this form.
If the IRS selects the designated
entity, then all members of the
controlled group that are required to
be listed on Schedule A of this form
will be deemed to have consented to
this election.

that is not an affiliated group. You
must also sign Part I on page 1 (see
Part I signature instructions below).
Also complete the first line of
Schedule A, with your NAIC company
and group code and net premiums
written, if any.

Box 2a. Check box 2a if you are the
agent of an affiliated group. You must
also sign Part I on page 1 (see Part I
signature instructions below). Also
complete the first line of Schedule A,
with your NAIC company and group
code and net premiums written, if any.

Number of controlled group members. Enter the number of controlled
group members who, as of the end of
the day on December 31, 2013, are
covered entities, including the entity in
box 2a or 2b. If reporting as a
single-person covered entity, enter 1
as the number of controlled group
members.
Entity name and address. If you
checked box 1, enter the name of the
single-person covered entity in the
entity name. If you checked box 2a or
2b, enter the name of the designated
entity. If you have a trade name or are
doing business under a different
name, enter that name or d/b/a name
on the “Entity name (continued)” line.

P.O. box. Enter your box number
only if your post office does not deliver
mail to your street address.
Third party. If you receive your mail
in care of a third party (such as an
accountant or an attorney), enter on
the first street address line “C/O”
followed by the third party's name and
enter the third party’s street address
or P.O. box on the second address
(continued) line.
Foreign address. If reporting a
foreign address, enter the foreign
country. If you file Form 8963
electronically, select the full name of
the country from the drop down in the
foreign country name box. Enter
foreign province or state, and postal
code.

Part II. Alternate Contact
Person Designee

If you want to designate an employee
to discuss the report with the IRS,
check the related box and enter the
person’s name, title, phone number,
and fax number, and we will contact
that person if we have any questions
concerning the report.

Schedule A. Single-Person
Covered Entity or Controlled
Group Member Information

Enter the single-person covered
entity, common parent of affiliated
group, or designated entity
information on the first line. This
information will automatically populate
the first line of Schedule A if you
complete the form electronically. It is
unnecessary to repeat the entity name
and address from page 1 on line 1,
but you must enter all of the premium
data requested for the entity.
Complete additional lines for each
controlled group member who, as of
the end of the day on December 31,
2013, is a covered entity, and enter
the following information for each
member.

(a) Employer identification number
(EIN). If filing your Form 8963
electronically, enter your 9-digit EIN
without the dash. The EIN will be
properly formatted for you.
(b) Entity name. If you have a trade
name or are doing business under a
different name, enter that name or
d/b/a name.

Box 2b. Check box 2b if you are the
designated entity for a covered entity
-2-

Page 3 of 4

Fileid: … ions/I8963/2013/A/XML/Cycle08/source

16:16 - 26-Nov-2013

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

(c) Address P.O. box. Enter your
box number only if your post office
does not deliver mail to your street
address.
Foreign address. If reporting a
foreign address, also include the full
name of the country using uppercase
letters in English. Enter the
information in the following order: city,
province or state, and postal code.

providing for dental only or vision only
coverage issued as a stand-alone
dental or vision policy, or as a rider to
a medical policy through deductibles
or out-of-pocket limits.
(i) Net premiums written. Enter the
total of columns (f) minus columns (g)
plus columns (h) in column (i). This is
100% of the amount of net premiums
written for the calendar year. The IRS
will compute net premiums written
taken into account (in accordance
with Regulations section 57.4(4)). If
negative, enter 0. Any negative
amounts will be treated as zero for fee
calculation purposes.
(j) Partial exclusion for certain exempt activities of 501(c)(3), (4),
(26) or (29) entities. Box 1. Enter
the number of the paragraph for the
partial exclusion for certain exempt
activities, if applicable. Allowable
selections are 3, 4, 26, or 29. If you
file Form 8963 electronically, select
the number of the paragraph from the
drop down.

D U te
R s
r
e
A
01 F O na
T
/0
nl l
2/ AS y
20
O
14 F

(d) and (e) National Association of
Insurance Commissioners (NAIC)
identification codes. Enter (d) NAIC
company code and (e) NAIC group
code for each single-person covered
entity, common parent of affiliated
group or designated entity, and each
controlled group member who, as of
the end of the day on December 31,
2013, is a covered entity. If you do not
have an NAIC company code or group
code for a covered entity or controlled
group member, leave the related field
blank.

the CCIIO, or those forms do not
contain the relevant data for
determining all of the direct premiums
written for health insurance for United
States health risks of an entity (or
member), enter comparable direct
premiums written information from any
equivalent form required by the state
of domicile of the entity (or member)
or by federal law.
If no single form contains all of the
relevant data for determining all of the
direct premiums written for health
insurance for United States health
risks of an entity (or member), then
direct premiums written must be
determined using aggregated data
from multiple forms.

(f) Direct premiums written.
Related acronyms:

In

Supplemental Health Care Exhibit
(SHCE),
Center for Consumer Information
and Insurance Oversight (CCIIO), and
Medical Loss Ratio (MLR) Annual
Reporting Form (MLR Form).
For each single-person covered
entity or member of a controlled
group, the source of data for
determining direct premiums written is
the SHCE, CCIIO MLR Form, or any
equivalent form required by the state
of domicile of the entity (or member)
or by federal law.
References to the NAIC SHCE and
the CCllO MLR Form in these
instructions are solely for your
convenience in identifying the
premium information required for this
report.
Generally, if the entity files an
SHCE with NAIC and/or an MLR Form
with CCllO, enter the direct premiums
written as reported for calendar year
ended December 31, 2013, to:
NAIC on your SHCE, Part 2,
line 1.1, columns 1 - 10; or
CCllO on the MLR Form, Part 2,
line 1.1, columns 1 - 35, amounts from
“Total as of 12/31/13” columns only.
If the entity does not file an SHCE
with the NAIC or an MLR Form with

(g) Medical loss ratio (MLR) rebates. Enter MLR rebates as you
reported for the calendar year ended
December 31, 2013, to:

NAIC on SHCE, Part 1, lines 5.3 to
5.5, column 15 total; or
CCIIO on the MLR Form, Part 1,
lines 2.7 to 2.9, column 1, “Total as of
12/31/13” only.
Figure the MLR rebates (current
year accrual), as below.
1. Rebates
paid

(from SHCE,
line 5.3, or
CCIIO MLR
Form,
line 2.7)

$ ________

2. Less:
Estimated
rebates
unpaid - prior
year

(from SHCE,
line 5.4, or
CCIIO MLR
Form,
line 2.8)

$ (_______)

3. Plus:
Estimated
rebates
unpaid current year

(from SHCE,
line 5.5, or
CCIIO MLR
Form,
line 2.9)

$ _______

4. MLR
rebates
(current year
accrual).
Enter this net
amount as a
positive
number in
column (g).

$ _______

Box 2. Enter the portion of net
premiums written included in the total
reported in column (i) for health
insurance premiums that are
attributable to certain exempt
activities of a covered entity qualifying
under paragraph (3), (4), (26), or (29)
of section 501(c) (ACA section
9010(b)(2)(B), partial exclusion for
certain exempt activities). Enter 100%
of these premiums that qualify for the
exclusion and the IRS will apply the
50% reduction after application of the
percentage of net premiums written
taken into account in ACA section
9010(b)(2)(A) (see (i) Net premiums
written above). If the amount entered
is greater than the net premiums
written reported in column (i), it will be
limited to the amount of column (i) for
that controlled group member for fee
calculation purposes.

Error Correction Process

(h) Stand-alone dental or vision direct premiums written. Enter the
amount of stand-alone dental or vision
direct premiums written as reported to
the NAIC on the SHCE, footnote (a). If
you do not file an SHCE, include
direct written premiums for policies
-3-

On receipt of the notification that
contains the 2014 preliminary fee
calculation from the IRS, a covered
entity must review the data contained
in the notification. If the covered entity
believes that the notification contains
one or more errors in the
mathematical calculation of the fee,
the net premiums written data, the net
premiums written after taking into

Page 4 of 4

Fileid: … ions/I8963/2013/A/XML/Cycle08/source

16:16 - 26-Nov-2013

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

account the application of Regulations
section 57.4(a)(4), or any other error,
the covered entity must provide a
corrected report to the IRS by July 15,
2014. The IRS will not accept
corrected Forms 8963 after this date.
The corrected report is to be made to
the IRS by completing, in full, a new
Form 8963, and checking the
"Corrected Report" box on the form.

disclosure. Do not include personal
information other than that required to
be disclosed.

Disclosure and Paperwork Reduction Act Notice. We ask for the
information on this form to carry out
the Internal Revenue laws of the
United States. You are required to
give us the information. We need it to
ensure that you are complying with
these laws and to allow us to figure
and collect the right amount of tax.

The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated average time is:

You are not required to provide the
information requested on a form that
is subject to the Paperwork Reduction
Act unless the form displays a valid
OMB control number. Books or
records relating to a form or its
instructions must be retained as long
as their contents may become
material in the administration of any
Internal Revenue law.

Recordkeeping . . . . . .

.

Learning about the
law or the form . . . . . .

.

Preparing the form . .

.

Copying, assembling,
and sending the form
to the IRS . . . . . . . . . .

In

D U te
R s
r
e
A
01 F O na
T
/0
nl l
2/ AS y
20
O
14 F

The covered entity may submit its
corrected Form 8963 either
electronically or by mail to the mailing
address listed above for filing the
initial Form 8963. The corrected Form
8963 will replace the originally filed
Form 8963; therefore, the corrected
report must contain all required
information in accordance with these
instructions for the form. An
attachment should be included with
the corrected Form 8963 if any item
being corrected requires further
explanation. In the case of a
controlled group, if the preliminary fee
calculation for the controlled group
contains one or more errors, the
corrected Form 8963 must include all
of the required information for the
entire controlled group, including
members that do not have
corrections. If a designated entity filed
a Form 8963 on behalf of the covered

entity, the designated entity must also
file any corrected report for the
covered entity.

Public Disclosure, Open to
Public Inspection. Although,
generally, tax returns and return
information are confidential, as
required by section 6103, the
information on this form is not
confidential and is not subject to
section 6103 pursuant to ACA section
9010, as amended. All information on
this form is subject to public

-4-

If you have comments concerning
the accuracy of these time estimates
or suggestions for making this form
simpler, we would be happy to hear
from you. You can write to:
Internal Revenue Service
Tax Forms and Publications
SE:W:CAR:MP:TFP
1111 Constitution Ave. NW,
IR-6526
Washington, DC 20224

Do not send the form to this office.
Instead, see Where To File, earlier.