Form 1094-B, Transmittal of Health Coverage Information Returns

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2014

Department of the Treasury
Internal Revenue Service

Instructions for Forms
1094-B and 1095-B
Section references are to the Internal Revenue Code
unless otherwise noted.

Future Developments

For the latest information about developments related to
Forms 1094-B, Transmittal of Health Coverage
Information Returns, and 1095-B, Health Coverage, and
the instructions, such as legislation enacted after they
were published, go to www.irs.gov/form1094b and
www.irs.gov/form1095b.

Reminders

Forms 1094-B and 1095-B are not required to be filed for
2014. However, in preparation for the first required filing of
these forms (that is, filing in 2016 for 2015), reporting
entities may, if they wish, voluntarily file in 2015 for 2014
in accordance with the forms and these instructions. For
more information about voluntary filing in 2015, visit
IRS.gov.

Additional Information

For information related to the Affordable Care Act, visit
www.irs.gov/ACA.
For the final regulations under section 6055, see T.D.
9660, 2014-13 I.R.B., at www.irs.gov/irb/2014-13_IRB/
ar08.html

General Instructions for Forms
1094-B and 1095-B
Form 1095-B is used to report certain information to the
IRS and to taxpayers about individuals who are covered
by minimum essential coverage and therefore are not
liable for the individual shared responsibility payment.
Minimum essential coverage includes
government-sponsored programs, eligible
employer-sponsored plans, individual market plans, and
miscellaneous coverage designated by the Department of
Health and Human Services. Minimum essential coverage
is described in more detail under Who Must File, later.
Minimum essential coverage does not include
coverage consisting solely of excepted benefits.
Excepted benefits include vision and dental
coverage not part of a comprehensive health insurance
plan, workers’ compensation coverage, and coverage
limited to a specified disease or illness.

TIP

Every person that provides minimum essential coverage
to an individual during a calendar year must file an
information return and a transmittal. Most filers will use
Forms 1094-B (transmittal) and 1095-B (return). However,
employers (including government employers) subject to
the employer shared responsibility provisions sponsoring
self-insured group health plans will report information
about the coverage in Part III of Form 1095-C,
Jan 28, 2015

Insured coverage. Health insurance issuers or carriers
must file Form 1095-B for most health insurance
coverage, including individual market coverage and
insured coverage sponsored by employers. However,
insurance issuers or carriers will not file Form 1095-B to
report coverage under the Childrens’ Health Insurance
Program (CHIP), Medicaid, and Medicare (including
Medicare Advantage) provided through health insurance
companies, which will be reported by the government
sponsors of those programs.
In addition, insurance issuers or carriers will not file
Form 1095-B to report coverage in individual market
qualified health plans that individuals enroll in through
Health Insurance Marketplaces, which will be reported by
Marketplaces on Form 1095-A. Health insurance issuers
will file Form 1095-B to report on coverage for employees
of small employers obtained through the Small Business
Health Options Program (SHOP).

Eligible Employer-Sponsored Plans

Purpose of Form

Who Must File

Employer-Provided Health Insurance Offer and Coverage,
instead of on Form 1095-B. In general, an employer with
50 or more full-time employees (including full-time
equivalent employees) during the prior calendar year is
subject to the employer shared responsibility provisions.
See the Instructions for Forms 1094-C and 1095-C for
more information about who must file Forms 1094-C and
1095-C. Small employers that are not subject to the
employer shared responsibility provisions sponsoring
self-insured group health plans will use Forms 1094-B and
1095-B to report information about covered individuals.

Eligible employer-sponsored plans include:
1. Group health insurance coverage for employees
under:
a. A governmental plan, such as the Federal
Employees Health Benefit program.
b. An insured plan or coverage offered in the small or
large group market within a state.
c. A grandfathered health plan offered in a group
market.
2. A self-insured group health plan for employees.
Health insurance issuers or carriers will file Form
1095-B for all insured employer coverage. Plan sponsors
are responsible for reporting self-insured employer
coverage. Plan sponsors that are employers subject to the
employer shared responsibility provisions must report the
coverage on Form 1095-C and other plan sponsors (such
as sponsors of multiemployer plans) report the coverage
on Form 1095-B.
Plan sponsors of self-insured employer coverage
include:
Each participating employer (for its own employees) in
a plan or arrangement established or maintained by
more than one employer;

Cat. No. 63017B

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b. CHAMPVA.

The association, committee, joint board of trustees, or
similar group of representatives who establish or
maintain a multiemployer plan;
The employee organization for a plan or arrangement
maintained solely by an employee organization; and
Each participating employer (for its own employees)
for a plan or arrangement maintained by a Multiple
Employer Welfare Arrangement.
A government employer may designate another
government entity to report coverage of its employees.
Generally, a designated government entity will file Form
1095-B on behalf of a government employer that sponsors
or maintains a self-insured group health plan for its
employees only if that government employer is not subject
to the employer shared responsibility provisions, which
would require reporting on Form 1095-C. The 2014
Instructions for Forms 1094-C and 1095-C contain further
information on reporting options for self-insured
government entities.

c. Comprehensive health care for children suffering
from spina bifida who are the children of Vietnam
veterans and veterans of covered service in
Korea.
6. Coverage for Peace Corps volunteers.
7. The Nonappropriated Fund Health Benefits Program
of the Department of Defense.
In general, the government agency sponsoring the
program will file Form 1095-B. The State agency that
administers a Medicaid or CHIP program will file Form
1095-B for coverage under those programs.
Miscellaneous minimum essential coverage. The
Department of Health and Human Services has
designated the following health benefit plans or
arrangements as minimum essential coverage:
1. Self-insured student health plans (for 2014 only).

Government-Sponsored Programs

Government-sponsored programs that are minimum
essential coverage are:

2. State high risk pools (for 2014 only).

1. Medicare Part A.

3. Coverage under Medicare Part C (Medicare
Advantage).

2. Medicaid, except for the following programs:

4. Refugee Medical Assistance.

a. Optional coverage of family planning services.

5. Coverage provided to business owners who are not
employees.

b. Optional coverage of tuberculosis-related
services.

6. Coverage under a group health plan provided through
insurance regulated by a foreign government if:

c. Coverage of pregnancy-related services in states
that do not provide full Medicaid benefits on the
basis of pregnancy.

a. A covered individual is physically absent from the
U.S. for at least 1 day during the month; or

d. Coverage of medical emergency services.

b. A covered individual is physically present in the
U.S. for a full month and the coverage provides
health benefits within the U.S. while the individual
is outside the U.S.

e. Coverage of medically-needy individuals.
f. Coverage under a section 1115 demonstration
waiver program.

Sponsors of these and later designated programs will
file Form 1095-B.

3. The Children’s Health Insurance Program (CHIP).

When To File

4. Coverage under the TRICARE program, except for
the following programs:

The return and transmittal form must be filed with the IRS
on or before February 28 (March 31 if filed electronically)
of the year following the calendar year of coverage.

a. Coverage on a space-available basis in a military
treatment facility for individuals who are not
eligible for TRICARE coverage for private sector
care.

You will meet the requirement to file if the form is
properly addressed and mailed on or before the due date.
If the regular due date falls on a Saturday, Sunday, or
legal holiday, file by the next business day. A business
day is any day that is not a Saturday, Sunday, or legal
holiday.

b. Coverage for a line of duty related injury, illness,
or disease for individuals who have left active
duty.
5. Coverage administered by the Department of
Veterans Affairs that is:

Note. The due date applies to forms filed in 2016
reporting coverage provided in calendar year 2015.

a. Coverage consisting of the medical benefits
package for eligible veterans.

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Instructions for Forms 1094-B and 1095-B 2014

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Statements Furnished to Individuals

Where To File

Send all information returns filed on paper to the following:
If your principal business,
office or agency, or legal
residence in the case of an
individual, is located in:
▼

Filers of Form 1095-B must furnish a copy to the person
identified as the responsible individual named on the form.
On Form 1095-B statements furnished to recipients,
filers of Form 1095-B may truncate the SSN (or other TIN,
if applicable) of an individual receiving coverage by
showing only the last four digits of the SSN (or other TIN)
and replacing the first five digits with asterisks (*) or Xs.
Truncation is not allowed on forms filed with the IRS.
Similarly, the filer’s employer identification number (EIN)
may be truncated on the statements furnished to
individuals but not on forms filed with the IRS.

Use the following address:
▼

Alabama, Arizona, Arkansas,
Connecticut, Delaware, Florida,
Georgia, Kentucky, Louisiana,
Maine, Massachusetts,
Mississippi, New Hampshire,
New Jersey, New Mexico, New
York, North Carolina, Ohio,
Pennsylvania, Rhode Island,
Texas, Vermont, Virginia,
West Virginia

Department of the Treasury
Internal Revenue Service
Center
Austin, TX 73301

Alaska, California, Colorado,
District of Columbia, Hawaii,
Idaho, Illinois, Indiana, Iowa,
Kansas, Maryland, Michigan,
Minnesota, Missouri, Montana,
Nebraska, Nevada, North
Dakota, Oklahoma, Oregon,
South Carolina, South Dakota,
Tennessee, Utah, Washington,
Wisconsin, Wyoming

Department of the Treasury
Internal Revenue Service
Center
Kansas City, MO 64999

Statements must be furnished on paper by mail, unless
the recipient affirmatively consents to receive the
statement in an electronic format. If mailed, the statement
must be sent to the recipient’s last known permanent
address, or if no permanent address is known, to the
recipient’s temporary address.
Consent to furnish statement electronically. The
requirement to obtain affirmative consent to furnish a
statement electronically ensures that statements are sent
electronically only to individuals who are able to access
them. A recipient may consent on paper or electronically,
such as by e-mail. If consent is on paper the recipient
must confirm the consent electronically. A statement may
be furnished electronically by e-mail or by informing the
recipient how to access the statement on the filer’s
website.

Specific Instructions for Form 1094-B
Line 1. Enter the filer’s complete name.

If your legal residence or principal place of business or
principal office or agency is outside the United States, file
with the Department of the Treasury, Internal Revenue
Service Center, Austin, TX 73301.

Line 2. Enter the filer’s nine-digit (EIN). If you do not have
an EIN, you may apply for one online. Go to IRS.gov and
enter “EIN” in the search box. You may also apply by
faxing or mailing Form SS-4, Application for Employer
Identification Number, to the IRS. See the Instructions for
Form SS-4 for more information. See Publication 1635,
Employer Identification Number, for further information.

How To File

Form 1094-B and Form
1095-B are subject to the
requirement to file returns
electronically. Filers of 250 or more information returns
(Forms 1095-B) must file Forms 1094-B and 1095-B
electronically. The 250-or-more requirement applies
separately to each type of return and separately to each
type of corrected return. Filers of fewer than 250 returns
may file electronically or on paper.

Lines 3 & 4. Enter the name and telephone number,
including area code, of the person to contact who is
responsible for answering any questions.
Lines 5-8. Enter the filer’s complete address where all
correspondence will be sent. If mail is delivered to a P.O.
Box and not a street address enter the box number
instead of the street address.

Publication 5165, Affordable Care Act (ACA) Information
Returns (AIR) Guide for Software Developers and
Transmitters, currently under development, will outline the
communication procedures, transmission formats,
business rules and validation procedures for returns filed
electronically through the AIR system. To develop
software for use with the AIR system, transmitters and
software developers should use the guidelines provided in
Publication 5165 along with the Extensible Markup
Language (XML) Schemas published on IRS.gov. See
Publication 5165 for more information.

Line 9. Enter the total number of Forms 1095-B that are
transmitted with Form 1094-B.

Specific Instructions for Form 1095-B
Part I—Responsible Individual (Policy Holder)
Line 1. Enter the name of the responsible individual. A
responsible individual may be a primary insured
employee, former employee, parent, uniformed services
sponsor, or other person enrolling individuals in coverage.
Do not enter the name of a business or business owner
that is the policy holder for its employees.

You will receive an electronic acknowledgment once you
complete the transaction. Keep it with your records.

Line 2. Enter the nine-digit social security number (SSN)
of the responsible individual (111-11-1111). Enter a
taxpayer identification number (TIN), rather than an SSN,
if the responsible individual does not have an SSN. No
SSN or other TIN is required if the responsible individual
is not a covered individual identified in Part IV. See

Corrected Forms 1094-B and 1095-B
Reserved.

Instructions for Forms 1094-B and 1095-B 2014

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Statements Furnished to Individuals, earlier, for
information on truncating the SSN or other TIN.

Column (e). If the individual was not covered for all
months check the applicable box(es) for the months in
which the individual was covered for at least one day. If
there are more than six covered individuals, complete one
or more additional Forms 1095-B, Part I lines 1 through 7
and Part IV. Do not include these additional Forms 1095-B
in the count of forms submitted with Form 1094-B.

Line 3. Enter the responsible individual’s date of birth
(MM/DD/YYYY) only if Line 2 is blank.
Line 4-7. Enter the complete mailing address of the
responsible individual. If mail is not delivered to the street
address and the responsible individual has a P.O. Box,
enter the box number instead of the street address.

Privacy Act and Paperwork Reduction Act Notice.
We ask for the information on these forms to carry out the
Internal Revenue laws of the United States and the
Patient Protection and Affordable Care Act. Our legal right
to ask for the information on this form is Internal Revenue
code 6055 and its regulations. We request it to confirm
that insured individuals are covered by minimum essential
coverage and therefore are not liable for the individual
shared responsibility payment. You are not required to
provide the information on these forms for 2014. If you do
not provide this information, we may be unable to
determine whether covered individuals are liable for the
individual shared responsibility payment; providing false
or fraudulent information may subject you to penalties. We
may disclose this information to the Department of Justice
for civil or criminal investigation, and to cities, states, and
the District of Columbia for use in administering their tax
laws. We may also disclose this information to other
countries under a tax treaty, to Federal and state agencies
to enforce Federal nontax criminal laws, or to Federal law
enforcement and intelligence agencies to combat
terrorism.

Line 8. Enter the letter identifying the origin of the policy.
A. Small Business Health Options Program (SHOP).
B. Employer-sponsored coverage.
C. Government-sponsored program.
D. Individual market insurance.
E. Multiemployer plan.
F. Miscellaneous minimum essential coverage.
Line 9. For 2014, leave this line blank.

Part II—Employer Sponsored Coverage

This part is completed only by issuers or carriers of
insured group health plans, including coverage purchased
through the SHOP.
Insurance companies entering codes A or B on
line 8 will complete Part II. Employers reporting
self-insured group health plan coverage on Form
1095-B enter code B on line 8, but do not complete Part II.
If you entered code B for self-insured coverage, skip Part
II and go to Part III.

TIP

Lines 10–15. Enter the name, EIN, and complete mailing
address for the employer sponsoring the coverage. If mail
is not delivered to the street address and the employer
has a P.O. Box, enter the box number instead of the street
address.

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. Generally, tax returns and return
information are confidential, as required by section 6103.

Part III—Issuer or Other Coverage Provider
Lines 16-22. Enter the name, EIN, and complete mailing
address of the provider of the coverage. The provider of
the coverage is the issuer or carrier of insured coverage,
sponsor of a self-insured employer plan, government
agency providing government-sponsored coverage, or
other entity. Enter on line 18 the telephone number the
individual seeking additional information may call to speak
to a person.

The time needed to complete the following forms will
vary depending on individual circumstances. The
estimated average time is:

Part IV—Covered Individuals
Column (a). Enter the name of each covered individual.

Form 1094-B . . . . . . . . . . . . . . .

10 minutes.

Form 1095-B . . . . . . . . . . . . . . .

1 hour.

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 the Internal Revenue Service; Tax Forms and
Publications Division; SE:W:CAR:MP:T, 1111 Constitution
Ave. NW, IR-6526, Washington, DC 20224. Do not send
the form to this office. Instead, see Where To File, earlier.

Column (b). Enter the nine-digit SSN for each covered
individual (111-11-1111). Enter a TIN, rather than an SSN,
if the covered individual does not have an SSN. See
Statements Furnished to Individuals, earlier, for
information on truncating the SSN or other TIN.
Column (c). Enter a date of birth (MM/DD/YYYY) for the
covered individual only if column (b) is blank.
Column (d). Check this box if the individual was covered
for at least one day per month for all 12 months of the
calendar year.

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Instructions for Forms 1094-B and 1095-B 2014