1095-B Health Coverage

Version C, Cycle 16
Fillable Fields: 10pt Helvetica Lt & Black; Checkbox Size: 12.5; Checkmark: Default

Form

1095-B

Department of the Treasury
Internal Revenue Service

Part I
1

560115

▶

5

8 Enter letter identifying Origin of the Policy (see instructions for codes):

12 Street address (including room or suite no.)

16

.

.

.

.

.

.

3 Date of birth (If SSN is not available)

6

State or province

7

9

Small Business Health Options Program (SHOP) Marketplace identifier, if applicable

Country and ZIP or foreign postal code

▶

11

Employer identification number (EIN)

Internal Use Only
DRAFT AS OF
January 26, 2015
13

City or town

14

State or province

15

Country and ZIP or foreign postal code

17

Employer identification number (EIN)

18

Contact telephone number

21

State or province

22

Country and ZIP or foreign postal code

Issuer or Other Coverage Provider

Name

19 Street address (including room or suite no.)

Part IV

City or town

2 Social security number (SSN)

Employer Sponsored Coverage (If Line 8 is A or B, complete this part.)

Employer name

Part III

2014

Responsible Individual (Policy Holder)

Name of responsible individual

Part II

OMB No. 1545-2252

CORRECTED

Information about Form 1095-B and its separate instructions is at www.irs.gov/form1095b.

4 Street address (including apartment no.)

10

VOID

Health Coverage

20

City or town

Covered Individuals (Enter the information for each covered individual(s).)
(a) Name of covered individual(s)

(b) SSN

(c) DOB (If SSN is not (d) Covered
available)
all 12 months

(e) Months of coverage

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

23

24

25

26

27

28
For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 60704B

Form 1095-B (2014)

Version C, Cycle 16
Fillable Fields: 10pt Helvetica Lt & Black; Checkbox Size: 12.5; Checkmark: Default

560215
Page 2

Form 1095-B (2014)

Instructions for Recipient
This Form 1095-B provides information needed to report on your income tax
return that you, your spouse, and individuals you claim as dependents had
qualifying health coverage (referred to as “minimum essential coverage”) for
some or all months during the year. Individuals who do not have minimum
essential coverage and do not qualify for an exemption may be 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. For more information on minimum essential coverage, see
Pub. 974, Premium Tax Credit (PTC).
Providers of minimum essential coverage are required to furnish
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to individuals covered under the policy if they request
it for their records.

TIP

Part I. Responsible Individual, lines 1–9. Part I reports information about
you and the coverage.
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
taxpayer identification number (TIN), if applicable. For your protection, this
form may show only the last four digits. However, the coverage provider is
required to report your complete SSN or other TIN, if applicable to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank.

!
▲

If you don't provide your SSN and the SSNs of all covered individuals
to the sponsor of the coverage, the IRS may not be able to match the
Form 1095-B with the individuals to determine that they have
CAUTION
complied with the individual shared responsibility provision.

Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
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
If you or another family member received health insurance
coverage through a Health Insurance Marketplace (also known as
an Exchange) that coverage will be reported on a Form 1095-A
rather than a Form 1095-B.

TIP

Line 9. This line will be blank for 2014.
Part II. Employer-Sponsored Coverage, lines 10–15. This part will be
completed by the insurance company if an insurance company provides your
employer-sponsored health coverage. It provides information about the
employer sponsoring the coverage. If your coverage is not insured employer
coverage, this part will be blank.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
information about the coverage provider (insurance company, employer
providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
coverage sponsor). Line 18 reports a telephone number for the coverage
provider that you can call if you have questions about the information
reported on the form.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN,
and coverage information for each covered individual. A date of birth will be
entered in column (c) only if an SSN 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 six covered
individuals, you will receive one or more additional Forms 1095-B that
continue Part IV.