Form 1094-C

2016

Department of the Treasury
Internal Revenue Service

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

www.irs.gov/for-Tax-Pros/Software-Developers/InformationReturns/Affordable-Care-Act-Information-Return-AIR-Program.

Future Developments

For FAQs specifically related to completing Forms 1094-C
and 1095-C, go to www.irs.gov/Affordable-Care-Act/Employers/
Questions-and-Answers-about-Information-Reporting-byEmployers-on-Form-1094-C-and-Form-1095-C.

For the latest information about developments related to Form
1094-C, Transmittal of Employer-Provided Health Insurance
Offer and Coverage Information Returns, and Form 1095-C,
Employer-Provided Health Insurance Offer and Coverage, and
instructions, such as legislation enacted after they were
published, go to www.irs.gov/form1094c and www.irs.gov/
form1095c.

What's New
Form revisions. On Form 1094-C, line 22, box B is designated
“Reserved.” The Qualifying Offer Method Transition Relief is not
applicable for 2016. In Part III, column (b), “Section 4980H” was
inserted before “Full-Time Employee Count for ALE Member” to
remind filers that the section 4980H definition of “full-time
employee” applies for purposes of this column, not any other
definition that an ALE Member may use for other purposes. On
Form 1095-C, the language “Do not attach to your tax return.
Keep for your records.” was inserted under the title of the form to
inform the recipient that Form 1095-C should not be submitted
with the return. On line 15 the heading was revised to read
“Employee Required Contribution (see instructions).” Other
minor clarifying changes were made to both forms.
Changes to codes. Code 1I for Form 1095-C, line 14, and
code 2I for Form 1095-C, line 16, are no longer applicable and
have been reserved. New codes 1J and 1K have been added for
Form 1095-C, line 14. For more information, see the instructions
for Form 1095-C, line 14 and line 16.
Transition relief. Several forms of transition relief were
available to employers for 2015 under sections 4980H and 6056,
but only limited transition relief continues to apply in 2016.
References to transition relief that applied only in calendar year
2015 have been removed. Descriptions of the remaining forms
of transition relief have been amended to clarify for which
months in 2016 the transition relief applies. For a description of
the relief and when it applies, see Section 4980H Transition
Relief for 2015 Plan Years.

Additional Information

General Instructions for
Forms 1094-C and 1095-C

See Definitions, later, for key terms used in these instructions.

Purpose of Form

Employers with 50 or more full-time employees (including
full-time equivalent employees) in the previous year use Forms
1094-C and 1095-C to report the information required under
sections 6055 and 6056 about offers of health coverage and
enrollment in health coverage for their employees. Form 1094-C
must be used to report to the IRS summary information for each
ALE Member and to transmit Forms 1095-C to the IRS. Form
1095-C is used to report information about each employee to the
IRS and to the employee. Forms 1094-C and 1095-C are used in
determining whether an ALE Member owes a payment under the
employer shared responsibility provisions under section 4980H.
Form 1095-C is also used in determining the eligibility of
employees for the premium tax credit.
ALE Members that offer employer-sponsored self-insured
coverage also use Form 1095-C to report information to the IRS
and to employees about individuals who have minimum
essential coverage under the employer plan and therefore are
not liable for the individual shared responsibility payment for the
months that they are covered under the plan.

Who Must File

For information related to the Affordable Care Act, visit
www.irs.gov/uac/Affordable-Care-Act-Tax-Provisions-Home. For
the final regulations under section 6056, Information Reporting
by Applicable Large Employers on Health Insurance Coverage
Offered Under Employer-Sponsored Plans, see T.D. 9661,
2014-13 I.R.B. 855, at www.irs.gov/irb/2014-13_IRB/ar09.html.
For the final regulations under section 6055, Information
Reporting on Minimum Essential Coverage, see T.D. 9660,
2014-13 I.R.B.842, at www.irs.gov/irb/2014–13_IRB/ar08.html.
For the final regulations under section 4980H, Shared
Responsibility for Employers Regarding Health Coverage, see
T.D. 9655, 2014-9 I.R.B. 541, at www.irs.gov/irb/2014-9_IRB/
ar05.html. For answers to frequently asked questions regarding
the employer shared responsibility provisions and related
information reporting requirements, visit IRS.gov. For information
related to filing Forms 1094-C and 1095-C electronically visit
Sep 29, 2016

For additional guidance and proposed regulatory changes
relating to section 6055, including clarifications regarding the
reporting requirements for providers of minimum essential
coverage and the requirement to solicit the TIN of each covered
individual for purposes of the reporting of health coverage
information, see Proposed Regulations section 1.6055-1(h) and
Regulations section 301.6724-1.

An ALE Member must file one or more Forms 1094-C (including
a Form 1094-C designated as the Authoritative Transmittal,
whether or not filing multiple Forms 1094-C), and must file a
Form 1095-C for each employee who was a full-time employee
of the ALE Member for any month of the calendar year.
Generally, the ALE Member is required to furnish a copy of the
Form 1095-C (or a substitute form) to the employee.
An ALE Member is, generally, a single person or entity that is
an Applicable Large Employer, or if applicable, each person or
entity that is a member of an Aggregated ALE Group. An
Applicable Large Employer, generally, is an employer with 50 or
more full-time employees (including full-time equivalent
employees) in the previous year. For purposes of determining if
an employer or group of employers is an Applicable Large
Employer, all ALE Members under common control (an
Aggregated ALE Group) are aggregated together. If the
Aggregated ALE Group, taking into account the employees of all

Cat. No. 63018M

ALE Members in the group, employed on average 50 or more
full-time employees (including full-time equivalent employees)
on business days during the preceding calendar year, then the
Aggregated ALE Group is an Applicable Large Employer and
each separate employer within the group is an ALE Member.
Each ALE Member is required to file Forms 1094-C and 1095-C
reporting offers of coverage to its full-time employees (even if the
ALE Member has fewer than 50 full-time employees of its own).

Reporting of Enrollment Information
for Non-Employees: Option
To Use Forms 1094-B and 1095-B
ALE Members that offer employer-sponsored self-insured health
coverage to non-employees who enroll in the coverage may use
Forms 1094-B and 1095-B, rather than Form 1095-C, Part III, to
report coverage for those individuals and other family members.
For this purpose, a non-employee includes, for example, a
non-employee director, an individual who was a retired
employee during the entire year, or a non-employee COBRA
beneficiary, including a former employee who terminated
employment during a previous year.

For more information on which employers are subject to the
employer shared responsibility provisions of section 4980H, see
Employer in the Definitions section of these instructions. For
more information on determining full-time employees, see
Full-Time Employee in the Definitions section of these
instructions, which includes information on the treatment of new
hires and employees in Limited Non-Assessment Periods.

For information on reporting for non-employees enrolled in an
employer-sponsored self-insured health plan using Forms
1094-B and 1095-B, see the instructions for those forms.

For purposes of reporting on Forms 1094-C and 1095-C,

TIP an employee in a Limited Non-Assessment Period is not
considered a full-time employee during that period.

For ALE Members that choose to use Form 1095-C to report
coverage information for non-employees enrolled in an
employer-sponsored self-insured health plan, see the specific
instructions for Form 1095-C, Part III—Covered Individuals
(Lines 17–22), later. Form 1095-C may be used only if the
individual identified on line 1 has an SSN.

Reporting by Employers That
Sponsor Self-Insured Health Plans
An employer that offers health coverage through a self-insured
health plan must report information about each individual
enrolled in such coverage. For an employer that is an ALE
Member, this information must be reported on Form 1095-C,
Part III, for any employee who is enrolled in coverage (and any
spouse or dependent of that employee). See below for the
option to file Form 1094-B and Form 1095-B, rather than Form
1094-C and Form 1095-C, to report coverage of certain
non-employees.

Substitute Statements to Recipients

If you are not using the official IRS form to furnish statements to
recipients, see Pub. 5223, General Rules and Specifications for
Affordable Care Act Substitute Forms 1095-A, 1094-B, 1095-B,
1094-C, and 1095-C, which explains the requirements for format
and content of substitute statements to recipients. You may
develop them yourself or buy them from a private printer.
Substitute statements furnished to recipients may be in portrait
format; however, substitute returns filed with the IRS using paper
must be printed in landscape format.

ALE Members that offer health coverage through an
employer-sponsored self-insured health plan must complete
Form 1095-C, Parts I, II, and III, for any employee who enrolls in
the health coverage, whether or not the employee is a full-time
employee for any month of the calendar year.

Authoritative Transmittal for ALE
Members Filing Multiple Forms 1094-C

A Form 1094-C must be filed when an ALE Member files one or
more Forms 1095-C. An ALE Member may choose to file
multiple Forms 1094-C, each accompanied by Forms 1095-C for
a portion of its employees, provided that a Form 1095-C is filed
for each employee for whom the ALE Member is required to file.
If an ALE Member files more than one Form 1094-C, one (and
only one) Form 1094-C filed by the ALE Member must be
identified on line 19, Part I as the Authoritative Transmittal, and,
on the Authoritative Transmittal, the ALE Member must report
certain aggregate data for all full-time employees and all
employees, as applicable, of the ALE Member.

For full-time employees enrolled in an ALE Member’s
self-insured coverage, including an employee who was a
full-time employee for at least one month of the calendar year,
the ALE Member must complete Form 1095-C, Part II, according
to the generally applicable instructions, and should not enter
code 1G on line 14 for any month. For an employee enrolled in
an ALE Member’s self-insured coverage who is not a full-time
employee for any month of the calendar year (meaning that for
all 12 calendar months the employee was not a full-time
employee), for Form 1095-C, Part II, the ALE Member must
enter code 1G on line 14 in the “All 12 Months” column or in the
separate monthly boxes for all 12 calendar months, and the ALE
Member need not complete Part II, lines 15 and 16.

Example 1. Employer A, an ALE Member, files a single
Form 1094-C, attaching Forms 1095-C for each of its 100
full-time employees. This Form 1094-C should be identified as
the Authoritative Transmittal on line 19, and the remainder of the
form completed as indicated in the instructions for line 19, later.

An employer that offers employer-sponsored self-insured
health coverage but is not an ALE Member should not file Forms
1094-C and 1095-C, but should instead file Forms 1094-B and
1095-B to report information for employees who enrolled in the
employer-sponsored self-insured health coverage.

Example 2. Employer B, an ALE Member, files two Forms
1094-C, one for each of its two operating divisions, Division X
and Division Y. (Division X and Division Y are units of the same
ALE Member, and thus both report under the same EIN; they are
not members of an Aggregated ALE Group.) Attached to one
Form 1094-C are Forms 1095-C for the 200 full-time employees
of Division X, and attached to the other Form 1094-C are Forms
1095-C for the 1,000 full-time employees of Division Y. One of
these Forms 1094-C should be identified as the Authoritative
Transmittal on line 19, and should include aggregate
employer-level data for all 1,200 full-time employees of
Employer B as well as the total number of employees of
Employer B, as applicable, as required in Parts II, III, and IV of
Form 1094-C. The other Form 1094-C should not be identified

Note. If an ALE Member is offering health coverage to
employees other than under a self-insured plan, such as through
an insured health plan or a multiemployer health plan, the issuer
of the insurance or the sponsor of the plan providing the
coverage is required to furnish the information about their health
coverage to any enrolled employees, and the ALE Member
should not complete Form 1095-C, Part III, for those employees.

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Instructions for Forms 1094-C and 1095-C (2016)

by that ALE Member for that calendar month. If under these
rules, an ALE Member is not required to report for an employee
for any month in the calendar year, the ALE Member is not
required to report for that full-time employee for that calendar
year. For a description of the rules related to determining which
ALE Member in an Aggregated ALE Group is treated as the
employer for a month in this situation, see the definition of
Employee.

as the Authoritative Transmittal on line 19, should report on
line 18 only the number of Forms 1095-C that are attached to
that Form 1094-C, and should leave the remaining sections of
the form blank as indicated in the instructions for line 19, later.
Note. Each ALE Member must file its own Forms 1094-C and
1095-C under its own separate EIN, even if the ALE Member is
part of an Aggregated ALE Group. No Authoritative Transmittal
should be filed for an Aggregated ALE Group.

Example. Employer A and Employer B are separate ALE
Members that belong to the same Aggregated ALE Group. Both
Employer A and Employer B offer coverage through the AB
health plan, which is an insured plan. In January and February,
Employee has 130 hours of service for Employer A and no hours
of service for Employer B. In March, Employee has 100 hours of
service for Employer A and 30 hours of service for Employer B.
In April through December, Employee has 130 hours of service
for Employer B and no hours of service for Employer A.
Employer A is the employer of Employee for filing purposes for
January, February, and March. Employer A should file Form
1095-C for Employee reporting offers of coverage using the
appropriate code on line 14 for January, February, and March,
should complete lines 15 and 16 per the instructions, and should
include Employee in the count of total employees and full-time
employees reported for those months on Form 1094-C. For the
months April through December, on Form 1095-C, Employer A
should enter code 1H (no offer of coverage) on line 14, leave
line 15 blank, and enter code 2A (not an employee) on line 16
(since Employee is treated as an employee of Employer B and
not as an employee of Employer A in those months), and should
exclude Employee from the count of total employees and
full-time employees reported for those months on Form 1094-C.

Example 3. Assume that Employer A from Example 1 is a
member of the same Aggregated ALE Group as Employer B
from Example 2. Accordingly, Employer A and Employer B are
separate ALE Members filing under separate EINs. Forms
1094-C should be filed in the same manner indicated in
Examples 1 and 2. Employer A should include only information
about employees of Employer A in its Authoritative Transmittal,
and Employer B should include only information about
employees of Employer B in its Authoritative Transmittal. No
Authoritative Transmittal should be filed for the Aggregated ALE
Group reporting combined data for employees of both Employer
A and Employer B.
Similar rules apply for a Governmental Unit that has
delegated its reporting responsibilities for some of its employees
to another Governmental Unit—see Designated Governmental
Entity (DGE) in the Definitions section of these instructions for
more information. In the case of a Governmental Unit that has
delegated its reporting responsibilities for some of its
employees, the Governmental Unit must ensure that among the
multiple Forms 1094-C filed by or on behalf of the Governmental
Unit transmitting Forms 1095-C for the Governmental Unit’s
employees, one of the filed Forms 1094-C is designated as the
Authoritative Transmittal and reports aggregate employer-level
data for the Governmental Unit, as required in Parts II, III, and IV
of Form 1094-C.

When To File

You will meet the requirement to file Forms 1094-C and 1095-C
if the forms are 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.

Example. County is an Aggregated ALE Group made up of
ALE Members School District, Police District, and County
General Office. School District designates the state to report on
behalf of the teachers and reports for itself for its remaining
full-time employees. In this case, either the School District or the
state must file an Authoritative Transmittal reporting aggregate
employer-level data for the School District.

Generally, you must file Forms 1094-C and 1095-C by
February 28 if filing on paper (or March 31 if filing electronically)
of the year following the calendar year to which the return
relates. For calendar year 2016, Forms 1094-C and 1095-C are
required to be filed by February 28, 2017, or March 31, 2017, if
filing electronically.

One Form 1095-C for Each
Employee of ALE Member

For each full-time employee of an ALE Member, there must be
only one Form 1095-C filed for employment with that ALE
Member. For example, if an ALE Member separately reports for
each of its two divisions, the ALE Member must combine the
offer and coverage information for any employee who worked at
both divisions during the calendar year so that a single Form
1095-C is filed for the calendar year for that employee which
reports information for all 12 months of the calendar year from
that ALE Member.

See Furnishing Forms 1095-C to Employees for information
on when Form 1095-C must be furnished.

Extensions
You can get an automatic 30-day extension of time to file by
completing Form 8809, Application for Extension of Time To File
Information Returns. The form may be submitted on paper, or
through the FIRE System either as a fill-in form or an electronic
file. No signature or explanation is required for the extension.
However, you must file Form 8809 on or before the due date of
the returns in order to get the 30-day extension. Under certain
hardship conditions you may apply for an additional 30-day
extension. See the instructions for Form 8809 for more
information.

In contrast, a full-time employee who works for more than one
ALE Member that is a member of the same Aggregated ALE
Group must receive a separate Form 1095-C from each ALE
Member. For any calendar month in which a full-time employee
works for more than one ALE Member of an Aggregated ALE
Group, only one ALE Member is treated as the employer of that
employee for reporting purposes (generally, the ALE Member for
whom the employee worked the greatest number of hours of
service), and only that ALE Member reports for that employee
for that calendar month. The other ALE Member is not required
to report for that employee for that calendar month, unless the
other ALE Member is otherwise required to file Form 1095-C for
that employee because the individual was a full-time employee
of that ALE Member for a different month of the same calendar
year. In this case, the individual may be treated as not employed
Instructions for Forms 1094-C and 1095-C (2016)

How to apply. As soon as you know that a 30-day extension of
time to file is needed, file Form 8809. See the instructions for
Form 8809. Mail or fax Form 8809 using the address and phone
number listed in the instructions. You can submit the extension
request online through the FIRE System. You are encouraged to
submit requests using the online fill-in form. See Pub. 1220, Part
B, for more information on filing online or electronically.

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Where To File

Electronic Filing

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:
▼
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

If your principal business,
office or agency, or legal
residence in the case of an
individual, is located in:
▼
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

If you are required to file 250 or more
information returns, you must file
electronically. The 250-or-more
requirement applies separately to each type of form filed and
separately for original and corrected returns. For example, if you
must file 500 Forms 1095-B and 100 Forms 1095-C, you must
file Forms 1095-B electronically, but you are not required to file
Forms 1095-C electronically. If you have 150 Forms 1095-C to
correct, you may file the corrected returns on paper because
they fall under the 250 threshold. However, if you have 300
Forms 1095-C to correct, they must be filed electronically. The
electronic filing requirement does not apply if you apply for and
receive a hardship waiver. The IRS encourages you to file
electronically even though you are filing fewer than 250 returns.

Use the following address:
▼

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

Waiver. To receive a waiver from the required filing of
information returns electronically, submit Form 8508. You are
encouraged to file Form 8508 at least 45 days before the due
date of the returns, but no later than the due date of the return.
The IRS does not process waiver requests until January 1st of
the calendar year the returns are due. You cannot apply for a
waiver for more than one tax year at a time. If you need a waiver
for more than one tax year, you must reapply at the appropriate
time each year. If a waiver for original returns is approved, any
corrections for the same types of returns will be covered under
the waiver. However, if you submit original returns electronically
but you want to submit your corrections on paper, a waiver must
be approved for the corrections if you must file 250 or more
corrections. If you receive an approved waiver, do not send a
copy of it to the service center where you file your paper returns.
Keep the waiver for your records only.
If you are required to file electronically but fail to do so, and
you do not have an approved waiver, you may be subject to a
penalty of $260 per return for failure to file electronically unless
you establish reasonable cause. However, you can file up to 250
returns on paper; those returns will not be subject to a penalty for
failure to file electronically. The penalty applies separately to
original returns and corrected returns.
Pub. 5165, Guide for Electronically Filing Affordable Care Act
(ACA) Information Returns for Software Developers and
Transmitters (currently under development for Processing Year
2017), specifies the communication procedures, transmission
formats, business rules, validation procedures, and explains
when a return will be accepted, accepted with errors or rejected
for returns filed electronically for calendar year 2016 through the
ACA Information Return (AIR) system. To develop software for
use with the AIR system, software developers, transmitters, and
issuers, including ALE Members filing their own Forms 1094-C
and 1095-C, should use the guidelines provided in Pub. 5165
along with the Extensible Markup Language (XML) Schemas
published on IRS.gov.
Reminder. The formatting directions in these instructions (for
example, the directions to enter the 9 digit EIN including the
dash on line 2 of Form 1094-C) are for the preparation of paper
returns. When filing forms electronically, the formatting set forth
in the XML Schemas and Business Rules published on IRS.gov
must be followed rather than the formatting directions in these
instructions. For more information regarding electronic filing, see
Pubs. 5164 and 5165.

Use the following address:
▼

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

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.
Shipping and mailing. If you are filing on paper, send the
forms to the IRS in a flat mailing (not folded), and do not
paperclip or staple the forms together. If you are sending many
forms, you may send them in conveniently sized packages. On
each package, write your name, number the packages
consecutively, and place Form 1094-C in package number one.
Postal regulations require forms and packages to be sent by
First-Class Mail.
Keeping copies. Generally, keep copies of information returns
you filed with the IRS or have the ability to reconstruct the data
for at least three years, from the due date of the returns.

Substitute Returns Filed with the IRS

If you are filing your returns on paper, see Pub. 5223 for
specifications for private printing of substitute information
returns. You may not request special consideration. Only forms
that conform to the official form and the specifications in Pub.
5223 are acceptable for filing with the IRS. Substitute returns
filed with the IRS must be printed in landscape format.

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Instructions for Forms 1094-C and 1095-C (2016)

VOID Box

See the charts for examples of errors and step by step

Do not use this box on Form 1095-C.

TIP instructions for filing corrected returns.

Corrected Forms 1094-C and 1095-C
Original Authoritative Transmittal Form 1094-C

For information about filing corrections electronically,

TIP see section 7.1 of Pub. 5165.

Corrected Returns
A corrected return should be filed as soon as possible after an
error is discovered. File the corrected returns as follows.
Form 1094-C. If correcting information on the Authoritative
Transmittal (identified on Part I, line 19, as the Authoritative
Transmittal, one (and only one) of which must be filed for each
ALE Member reporting aggregate employer-level data for all
full-time employees and employees of the ALE Member), file a
standalone fully completed Form 1094-C including the correct
information and enter an “X” in the CORRECTED checkbox. Do
not file a return correcting information on a Form 1094-C that is
not the Authoritative Transmittal.

!

THEN ...

ALE Member or Designated
Government Entity (Name and/or
EIN)

1. Prepare a new Authoritative
Transmittal, Form 1094-C
2. Enter an “X” in the “CORRECTED”
box at the top of the form

Total Number of Forms 1095-C filed
by and/or on behalf of ALE Member
3. Submit the standalone corrected
Form 1094-C with the correct
information present
Aggregated ALE Group Membership
Certifications of Eligibility

Do not file any other documents (e.g. Form 1095-C)
with the corrected Authoritative Transmittal.

Minimum Essential Coverage Offer
Indicator

CAUTION

Form 1095-C. If correcting information on a Form 1095-C
that was previously filed with the IRS, file a fully completed Form
1095-C including the correct information and enter an “X” in the
CORRECTED checkbox. File a Form 1094-C (Do not mark the
CORRECTED checkbox on Form 1094-C) with corrected
Form(s) 1095-C. Furnish the employee a copy of the corrected
Form 1095-C, unless the ALE Member was and continues to be
eligible for and used the alternative method of furnishing under
the Qualifying Offer Method for that employee for that year’s
furnishing. For more information, see Alternative Method of
Furnishing Form 1095-C to Employees under the Qualifying
Offer Method.

Section 4980H Full-Time Employee
Count for ALE Member
Aggregated Group Indicator
Section 4980H Transition Relief
Indicator
Other ALE Members of Aggregated
ALE Group (Name and/or EIN)

Note. Enter an “X” in the CORRECTED checkbox only when
correcting a Form 1095-C previously filed with the IRS. If you are
correcting a Form 1095-C that was previously furnished to a
recipient, but not filed with the IRS, write, type, or print
CORRECTED on the new Form 1095-C furnished to the
recipient.

Original Form 1095-C Submitted to IRS and Furnished to Employee

Correcting information affecting statement furnished to
employee using an Alternative Furnishing Method under
the Qualifying Offer Method. If an ALE Member eligible to use
the Qualifying Offer Method had furnished the employee an
alternative statement, the ALE Member must furnish the
employee a corrected statement if it filed a corrected Form
1095-C correcting the ALE Member’s name, EIN, address or
contact name and telephone number. If the ALE Member is no
longer eligible to use an alternative furnishing method for the
employee for whom it filed a corrected Form 1095-C, it must
furnish a Form 1095-C to the employee and advise the
employee that Form 1095-C replaces the statement it had
previously furnished.

IF any of the following are
incorrect ....

THEN ...

Name, SSN, ALE Member EIN

1. Prepare a new Form 1095-C

Offer of Coverage

2. Enter an “X” in the “CORRECTED”
box at the top of the form

Employee Required Contribution

3. Submit corrected Form 1095-Cs with
a non-authoritative Form 1094-C
transmittal to the IRS

Section 4980H Safe Harbor and
Other Relief Codes
4. Furnish a corrected Form 1095-C to
the employee
Covered Individuals Information

If you fail to file correct information returns or fail to
furnish a correct recipient statement, you may be subject
CAUTION to a penalty. Regulations section 301.6724-1 (relating to
information return penalties) does not require you to file
corrected returns for missing or incorrect TINs if you meet the
reasonable cause criteria. For additional information, see Pub.
1586, Reasonable Cause Regulations and Requirements for
Missing and Incorrect Name/TINs.

!

Instructions for Forms 1094-C and 1095-C (2016)

IF any of the following are
incorrect ....

-5-

on the ALE Member’s website. Statements reporting coverage
under an expatriate health plan, however, may be furnished
electronically unless the recipient explicitly refuses to consent to
receive the statement in an electronic format. Specific
information on consents to furnish statements electronically can
be found in Regulations section 301.6056-2.

Original Alternative Furnishing Method under the Qualifying Offer
Method Statement Furnished to Employee
IF any of the following are
incorrect ....

THEN ...

Name, SSN, ALE Member EIN

• Submission to IRS:
1. Prepare a new Form 1095-C
2. Enter an “X” in the “CORRECTED”
box at the top of the form
3. Submit corrected Form 1095-Cs
with a non-authoritative Form 1094-C
transmittal to the IRS

Offer of Coverage

Extensions of time to furnish statement to recipients. You
may request an extension of time to furnish the statements to
recipients by sending a letter to Internal Revenue Service, Attn:
Extension of Time Coordinator, 240 Murall Drive, Mail Stop
4360, Kearneysville, WV 25430. The letter must include (a) filer
name, (b) filer TIN, (c) filer address, (d) type of return, (e) a
statement that extension request is for providing statements to
recipients, (f) reason for delay, and (g) the signature of the filer
or authorized agent. Your request must be postmarked by the
date on which the statements are due to the recipients. If your
request for an extension is approved, generally you will be
granted a maximum of 30 extra days to furnish the recipient
statements. For purposes of requesting an extension of time to
furnish the statements, the term filer means the ALE Member, or
the Designated Government Entity, if applicable.

• Furnish to employee
If after the correction the ALE Member
is still eligible to use the alternative
furnishing method under the Qualifying
Offer Method, furnish the employee
either a Form 1095-C or corrected
statement.
If the ALE Member is no longer eligible
to use the alternative furnishing method
with respect to the employee, furnish a
Form 1095-C to the employee.

Information reporting penalties. All employers subject to the
employer shared responsibility provisions and other employers
that sponsor self-insured group health plans that fail to comply
with the applicable information reporting requirements may be
subject to the general reporting penalty provisions for failure to
file correct information returns and failure to furnish correct
payee statements. For returns required to be made and
statements required to be furnished for 2016 tax year returns,
the following apply.
The penalty for failure to file a correct information return is
$260 for each return for which the failure occurs, with the total
penalty for a calendar year not to exceed $3,193,000.
The penalty for failure to provide a correct payee statement is
$260 for each statement for which the failure occurs, with the
total penalty for a calendar year not to exceed $3,193,000.
Special rules apply that increase the per-statement and total
penalties if there is intentional disregard of the requirement to file
the returns and furnish the required statements.
Waiver of penalties. Penalties may be waived if the failure
was due to reasonable cause and not willful neglect. See section
6724 and Regulations section 301.6724-1 and Proposed
Regulations section 1.6055-1(h) (which relate to Form 1095-C,
Part III). For additional information, see Pub. 1586.

Furnishing Forms 1095-C To Employees

You will meet the requirement to furnish Form 1095-C to an
employee 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.
An ALE Member must furnish a Form 1095-C to each of its
full-time employees by January 31 of the year following the year
to which the Form 1095-C relates.
Forms 1095-C for the 2016 calendar year must be furnished
by January 31, 2017.
For more information on alternative furnishing methods for
employers, see A. Qualifying Offer Method.
Filers of Form 1095-C may truncate the social security
number (SSN) of an individual (the employee or any family
member of the employee receiving coverage) on Form 1095-C
statements furnished to employees by showing only the last four
digits of the SSN and replacing the first five digits with asterisks
(*) or Xs. Truncation is not allowed on forms filed with the IRS. In
addition, an ALE Member's employer identification number (EIN)
may not be truncated on the statements furnished to employees
or the forms filed with the IRS.

Specific Instructions for Form 1094-C
Part I—Applicable Large Employer Member
(ALE Member)
Line 1. Enter employer's name. The employer is the ALE
Member.

Except as provided below, statements must be furnished on
paper by mail (or hand delivered), unless the recipient
affirmatively consents to receive the statement in an electronic
format. If mailed, the statement must be sent to the employee’s
last known permanent address, or if no permanent address is
known, to the employee’s temporary address.

Line 2. Enter the ALE Member’s Employer Identification
Number (EIN). Do not enter an SSN. Enter the 9-digit EIN
including the dash.
If you are filing Form 1094-C, a valid EIN is required at
the time the form is filed. If a valid EIN is not provided,
CAUTION Form 1094-C will not be processed. 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 and Pub. 1635,
Employer Identification Number.

!

Consent to furnish statement electronically. An ALE
Member is required to obtain affirmative consent to furnish a
statement electronically. This requirement ensures that
statements are furnished electronically only to individuals who
are able to access them. The consent must relate specifically to
receiving the Form 1095-C electronically. An individual may
consent on paper or electronically, such as by email. If consent
is on paper, the individual must confirm the consent
electronically. A statement may be furnished electronically by
email or by informing the individual how to access the statement

Lines 3–6. Enter the ALE Member’s complete address
(including room or suite no., if applicable). This address should
match the ALE Member’s address used on Form 1095-C.
-6-

Instructions for Forms 1094-C and 1095-C (2016)

Line 21. If during any month of the calendar year the ALE
Member was a member of an Aggregated ALE Group, check
“Yes.” If you check “Yes,” also complete the “Aggregated Group
Indicator” in Part III, column (d), and then complete Part IV to list
the other members of the Aggregated ALE Group. If, for all 12
months of the calendar year, the employer was not a member of
an Aggregated ALE Group, check “No,” and do not complete
Part III, column (d), or Part IV.

Lines 7 and 8. Enter the name and telephone number of the
person to contact who is responsible for answering any
questions from the IRS regarding the filing of or information
reported on Forms 1094-C or 1095-C. (This may be different
than the contact information on line 10 of Form 1095-C.)
Note. If you are a Designated Governmental Entity (DGE) filing
on behalf of an ALE Member, complete lines 9–16. If you are not
a DGE filing on behalf of an ALE Member do not complete lines
9–16. Instead, skip to line 18. See Designated Governmental
Entity (DGE) in the Definitions section of these instructions.

Line 22. If the ALE Member meets the eligibility requirements
and is using one of the Offer Methods and/or one of the forms of
Transition Relief indicated, it must check each applicable box.
See the descriptions of Qualifying Offer Method, Section 4980H
Transition Relief, and 98% Offer Method, below.
A. Qualifying Offer Method. Check this box if the ALE
Member is eligible to use and is using the Qualifying Offer
Method to report the information on Form 1095-C for one or
more full-time employees. Under the Qualifying Offer Method
there is an alternative method of completing Form 1095-C and
an alternative method for furnishing Form 1095-C to certain
employees. If the ALE Member is using either of these
alternative rules, check this box. To be eligible to use the
Qualifying Offer Method, the ALE Member must certify that it
made a Qualifying Offer to one or more of its full-time employees
for all months during the year in which the employee was a
full-time employee for whom an employer shared responsibility
payment could apply. Additional requirements described below
must be met to be eligible to use the alternative method for
furnishing Form 1095-C to employees under the Qualifying Offer
Method.
Alternative Method of Completing Form 1095-C under
the Qualifying Offer Method. If the ALE Member reports using
this method, it must not complete Form 1095-C, Part II, line 15,
for any month for which a Qualifying Offer is made. Instead it
must enter the Qualifying Offer code 1A on Form 1095-C,
line 14, for any month for which the employee received a
Qualifying Offer (or in the all 12 months box if the employee
received a Qualifying Offer for all 12 months), and must leave
line 15 blank for any month for which code 1A is entered on
line 14. The ALE Member may, but is not required, to enter an
applicable code on line 16 for any month for which code 1A is
entered on line 14; a Qualifying Offer is, by definition, treated as
an offer that falls within an affordability safe harbor even if no
code is entered on line 16.
An ALE Member is not required to use the Qualifying Offer
Method, even if it is eligible and instead may enter on line 14 the
applicable offer code and then enter on line 15 the Employee
Required Contribution.

Line 9. If a DGE is filing on behalf of the ALE Member, enter the
name of the DGE.
Line 10. Enter the DGE’s EIN (including the dash). Do not enter
an SSN.
If you are a DGE that is filing Form 1094-C, a valid EIN is
required at the time the return is filed. If a valid EIN is not
CAUTION provided, the return will not be processed. If the DGE
does not have an EIN when filing Form 1094-C it can get an EIN
by applying online at IRS.gov or by faxing or mailing a completed
Form SS-4. See the Instructions for Form SS-4 and Pub. 1635.

!

Lines 11–14. Enter the DGE’s complete address (including
room or suite no), if applicable.
Lines 15 and 16. Enter the name and telephone number of the
person to contact who is responsible for answering any
questions from the IRS regarding the filing of or information
reported on Form 1094-C.
Line 17. Reserved.
Line 18. Enter the total number of Forms 1095-C (not counting
continuation sheets) submitted with this Form 1094-C
transmittal.
Line 19. If this Form 1094-C transmittal is the Authoritative
Transmittal that reports aggregate employer-level data for the
ALE Member, check the box on line 19 and complete Parts II, III,
and IV, to the extent applicable. Otherwise, complete the
signature portion of Form 1094-C and leave the remainder of
Parts II, III, and IV blank.
There must be only one Authoritative Transmittal filed for
each ALE Member. If this is the only Form 1094-C being filed for
the ALE Member, this Form 1094-C must report aggregate
employer-level data for the ALE Member and be identified on
line 19 as the Authoritative Transmittal. If multiple Forms 1094-C
are being filed for an ALE Member so that Forms 1095-C for all
full-time employees of the ALE Member are not attached to a
single Form 1094-C transmittal (because Forms 1095-C for
some full-time employees of the ALE Member are being
transmitted separately), one (and only one) of the Forms 1094-C
must report aggregate employer-level data for the ALE Member
and be identified on line 19 as the Authoritative Transmittal. For
more information, see Authoritative Transmittal for ALE
Members Filing Multiple Forms 1094-C, earlier.

If the ALE Member is eligible to use the Qualifying Offer

TIP Method, it may report on Form 1095-C by entering the

Qualifying Offer code 1A on Form 1095-C, line 14, for
any month for which it made a Qualifying Offer to an employee,
even if the employee did not receive a Qualifying Offer for all 12
calendar months. However, if an employee receives a Qualifying
Offer for less than all 12 months, the ALE Member must furnish a
copy of Form 1095-C to the employee (rather than using the
alternative method of furnishing Form 1095-C described below).

Part II—ALE Member Information
Reminder. Lines 20–22 should be completed only on the
Authoritative Transmittal for the ALE Member. For more
information, see Authoritative Transmittal for ALE Members
Filing Multiple Forms 1094-C, earlier.

Example. Employee’s employment with Employer begins on
January 1. Employee is in a health coverage waiting period (and
an employer shared responsibility payment could not apply with
respect to Employee, because Employee is in a Limited
Non-Assessment Period) until April 1 and is a full-time employee
for the remainder of the calendar year. Employer makes a
Qualifying Offer to Employee for coverage beginning on April 1
and for the remainder of the calendar year. Employer is eligible
to use the Qualifying Offer method because it has made a
Qualifying Offer to at least one full-time employee for all months
in which both (1) the employee was a full-time employee and (2)

Line 20. Enter the total number of Forms 1095-C (not counting
continuation sheets) that will be filed by and/or on behalf of the
ALE Member. This includes all Forms 1095-C that are filed with
this transmittal including those filed for individuals who enrolled
in the employer-sponsored self-insured plan, if any, and for any
Forms 1095-C filed with a separate transmittal filed by or on
behalf of the ALE Member.
Instructions for Forms 1094-C and 1095-C (2016)

-7-

use the 98% Offer Method, an employer must certify that, taking
into account all months during which the individuals were
employees of the ALE Member and were not in a Limited
Non-Assessment Period, the ALE Member offered, affordable
health coverage providing minimum value to at least 98% of its
employees for whom it is filing a Form 1095-C employee
statement, and offered minimum essential coverage to those
employees’ dependents. The ALE member is not required to
identify which of the employees for whom it is filing were full-time
employees, but the ALE Member is still required, under the
general reporting rules, to file Forms 1095-C on behalf of all its
full-time employees who were full-time employees for one or
more months of the calendar year. To ensure compliance with
the general reporting rules, an ALE Member should confirm for
any employee for whom it fails to file a Form 1095-C that the
employee was not a full-time employee for any month of the
calendar year. (For this purpose, the health coverage is
affordable if the ALE Member meets one of the section 4980H
affordability safe harbors.)

an employer shared responsibility payment could apply with
respect to the employee. Employer may use the alternative
method of completing Form 1095-C under the Qualifying Offer
Method for this Employee. However, Employer may not use the
alternative method of furnishing Form 1095-C to Employee
under the Qualifying Offer Method because Employee did not
receive a Qualifying Offer for all 12 months of the calendar year.
Alternative Method of Furnishing Form 1095-C to
Employees under the Qualifying Offer Method. An ALE
Member that is eligible to use the Qualifying Offer Method may
use the alternative method of furnishing Form 1095-C only for a
full-time employee who: (1) received a Qualifying Offer for all 12
months of the calendar year, and (2) did not enroll in
employer-sponsored self-insured coverage. For such an
employee, an ALE Member meets its obligation to furnish a
Form 1095-C to the employee if it furnishes the employee a
statement containing the following information.
Employer/ALE Member name, address, and EIN.
Contact name and telephone number at which the employee
may receive information about the offer of coverage and the
information on the Form 1095-C filed with the IRS for that
employee.
Notification that, for all 12 months of the calendar year, the
employee and his or her spouse and dependents, if any,
received a Qualifying Offer and therefore are not eligible for a
premium tax credit.
Information directing the employee to see Pub. 974, Premium
Tax Credit (PTC), for more information on eligibility for the
premium tax credit.
An ALE Member is not required to use the alternative method
of furnishing for an employee even if the alternative method
would be allowed. Instead, the ALE Member may furnish a copy
of Form 1095-C as filed with the IRS (with or without the
statement described above).
As stated above, an ALE Member may not use the alternative
furnishing method for a full-time employee who enrolled in
self-insured coverage. Rather, the ALE Member must furnish
Form 1095-C, including the information reporting enrollment in
the coverage on Form 1095-C, Part III.
B. Reserved.
C. Section 4980H Transition Relief. For the 2016 calendar
year, the transition relief described below is applicable only if an
ALE Member (or any other member of the ALE Member’s
Aggregated ALE Group, if applicable) offers coverage under a
health plan with a plan year beginning on a date other than
January 1 (a non-calendar year plan year), and only for calendar
months in 2016 that fall within that 2015 plan year. Check this
box if the ALE Member is eligible for section 4980H Transition
Relief for one or more months of the 2016 calendar year under
either:
2015 Plan Year Section 4980H Transition Relief for ALEs with
Fewer Than 100 Full-Time Employees, Including Full-Time
Equivalent Employees (50-99 Transition Relief), or
2015 Plan Year Transition Relief for Calculation of Assessable
Payments Under Section 4980H(a) for ALEs with 100 or More
Full-Time Employees, Including Full-Time Equivalent Employees
(100 or More Transition Relief).
For a description of the relief, including which ALE Members
are eligible for the relief, and to which months in 2016 the relief
may apply, including if the ALE Member (or any member of the
ALE Member’s Aggregated ALE Group, if applicable) sponsors
more than one plan, see Section 4980H Transition Relief for
2015 Plan Years, later. If an ALE Member checks this box, it
must also indicate the type of section 4980H transition relief on
Form 1094-C, Part III, column (e), Section 4980H Transition
Relief Indicator, for each month to which the relief applies.
D. 98% Offer Method. Check this box if the employer is
eligible for and is using the 98% Offer Method. To be eligible to

Example. Employer has 325 employees. Of those 325
employees, Employer identifies 25 employees as not possibly
being full-time employees because they are scheduled to work
10 hours per week and are not eligible for additional hours. Of
the remaining 300 employees, 295 are offered affordable
minimum value coverage for all periods during which they are
employed other than any applicable waiting period (which
qualifies as a Limited Non-Assessment Period). Employer files a
Form 1095-C for each of the 300 employees (excluding the 25
employees that it identified as not possibly being full-time
employees). Employer may use the 98% Offer Method because
it makes an affordable offer of coverage that provides minimum
value to at least 98% of the employees for whom Employer files
a Form 1095-C. Using this method, Employer does not identify
whether each of the 300 employees is a full-time employee.
However, Employer must still file a Form 1095-C for all of its
full-time employees. Employer chooses to file a Form 1095-C on
behalf of all 300 employees, including the five employees to
whom it did not offer coverage, because if one or more of those
employees was, in fact, a full-time employee for one or more
months of the calendar year, Employer would be required to
have filed a Form 1095-C on behalf of those employees.
Note. If an ALE member uses the 98% offer method, it is not
required to complete the “Section 4980H Full-Time Employee
Count for ALE Member” in Part III, column (b).

Part III—ALE Member Information—Monthly
(Lines 23–35)
Column (a) Minimum Essential Coverage Offer Indicator.
If the ALE Member offered minimum essential coverage to at
least 95% of its full-time employees and their dependents for the
entire calendar year, enter “X” in the “Yes” checkbox on line 23
for “All 12 Months” or for each of the 12 calendar months.
If the ALE Member offered minimum essential coverage to at
least 95% of its full-time employees and their dependents only
for certain calendar months, enter “X” in the “Yes” checkbox for
each applicable month.
For the months, if any, for which the ALE Member did not offer
minimum essential coverage to at least 95% of its full-time
employees and their dependents, enter “X” in the “No” checkbox
for each applicable month.
If the ALE Member did not offer minimum essential coverage
to at least 95% of its full-time employees and their dependents
for any of the 12 months, enter “X” in the “No” checkbox for “All
12 Months” or for each of the 12 calendar months.
However, for ALE Members with non-calendar year plans, an
ALE Member that did not offer minimum essential coverage to at
least 95% of its full-time employees and their dependents but is
-8-

Instructions for Forms 1094-C and 1095-C (2016)

measurement period that corresponds with the stability period
starting January 1, 2016, and ending December 31, 2016.
Employee terminates employment with Employer on February
15, 2016. Employer must include Employee in the number of
full-time employees reported in column (b) for January and
February. See the description of code 2B in the instructions for
line 16 of Form 1095-C, later, for rules for reporting an offer of
coverage in an employee’s final month of employment.

eligible for certain transition relief described in the instructions
later under Section 4980H Transition Relief for 2015 Plan Years
should enter an “X” in the “Yes” checkbox for Part III, column (a),
for months to which the transition relief is applicable. This
transition relief is available in 2016 only for ALE Members with
plans with a non-calendar year plan year; for such an ALE
Member, the relief applies only to the calendar months in 2016
that fall within the 2015 plan year. See the instructions later
under Section 4980H Transition Relief for 2015 Plan Years.

Note. If the ALE Member certified that it was eligible for the 98%
Offer Method by selecting box D, on line 22, it is not required to
complete column (b).

Note. For purposes of column (a), an employee in a Limited
Non-Assessment Period is not counted in determining whether
minimum essential coverage was offered to at least 95% (or
70%) of an ALE Member’s full-time employees and their
dependents. For a description of the differences between the
definition of the term Limited Non-Assessment Period used with
respect to section 4980H(a) and the definition used with respect
to section 4980H(b), relating to whether the ALE Member offers
minimum value coverage at the end of the Limited
Non-Assessment Period, see the Definitions section.

Column (c) Total Employee Count for ALE Member. Enter
the total number of all of the ALE Member’s employees,
including full-time employees and non-full-time employees, and
employees in a Limited Non-Assessment Period, for each
calendar month. An ALE Member must choose to use one of the
following days of the month to determine the number of
employees per month and must use that day for all months of the
year: (1) the first day of each month; (2) the last day of each
month; (3) the 12th day of each month; (4) the first day of the first
payroll period that starts during each month; or (5) the last day of
the first payroll period that starts during each month (provided
that for each month that last day falls within the calendar month
in which the payroll period starts). If the total number of
employees was the same for every month of the entire calendar
year, enter that number in line 23, column (c) “All 12 Months” or
in the boxes for each month of the calendar year. If the number
of employees for any month is zero, enter “0.”

An employee who is treated as having been offered

TIP health coverage for purposes of section 4980H (even

though not actually offered) is treated as offered
minimum essential coverage for this purpose. For example, for
the months for which the ALE Member is eligible for dependent
coverage transition relief or multiemployer arrangement interim
guidance (if the ALE Member is contributing on behalf of an
employee whether or not the employee is eligible for coverage
under the multiemployer plan) with respect to an employee, that
employee should be treated as having been offered minimum
essential coverage for purposes of column (a). For more
information on the dependent coverage transition relief, which is
available in 2016 only for ALE Members with plans with a
non-calendar year plan year and only for the calendar months in
2016 that fall within the 2015 plan year, see Section 4980H
Transition Relief for 2015 Plan Years. For different rules for
purposes of reporting offers of coverage on Form 1095-C, see
the specific instructions for Form 1095-C, Part II, line 14.

Column (d) Aggregated Group Indicator. An ALE Member
must complete this column if it checked “Yes” on line 21,
indicating that, during any month of the calendar year, it was a
member of an Aggregated ALE Group. If the ALE Member was a
member of an Aggregated ALE Group during each month of the
calendar year, enter “X” in the “All 12 Months” box or in the
boxes for each of the 12 calendar months. If the ALE Member
was not a member of an Aggregated ALE Group for all 12
months but was a member of an Aggregated ALE Group for one
or more month(s), enter “X” in each month for which it was a
member of an Aggregated ALE Group. If an ALE Member enters
“X” in one or more months in this column, it must also complete
Part IV.

For purposes of column (a), if the ALE Member offered

TIP minimum essential coverage to all but five of its full-time

employees and their dependents, and five is greater
than 5% of the number of full-time employees of the ALE
Member, the ALE Member may report in column (a) as if it
offered health coverage to at least 95% of its full-time employees
and their dependents (even if it offered health coverage to less
than 95% of its full-time employees and their dependents, for
example to 75 of its 80 full-time employees and their
dependents).

Column (e) Section 4980H Transition Relief Indicator. If the
ALE Member certifies by selecting box C on line 22, that it is
eligible for Section 4980H Transition Relief and is eligible for the
50 to 99 Relief, enter code A for each month to which the
transition relief applies. If the ALE Member certifies by selecting
box C on line 22, that it is eligible for Section 4980H Transition
Relief and is eligible for the 100 or More Relief, enter code B for
each month to which the transition relief applies. An ALE
Member will not be eligible for both types of relief. This transition
relief is available in 2016 only for ALE Members with plans with a
non-calendar year plan year or for ALE Members that are
members of an Aggregated ALE Group with at least one plan
with a non-calendar year plan year. For such an ALE Member,
the relief applies only to the calendar months in 2016 that fall
within the 2015 plan year. If any ALE Member, or different
members in an Aggregated ALE Group, offer coverage under
more than one health plan with different plan years, the transition
relief applies through the last day of the latest of those plan
years. See 4980H Transition Relief for 2015 Plan Years, later.

See Definitions, later, for more information on an offer of
health coverage.
Column (b) Section 4980H Full-Time Employee Count for
ALE Member. Enter the number of full-time employees for each
month, but do not count any employee in a Limited
Non-Assessment Period. If the number of full-time employees
(excluding employees in a Limited Non-Assessment Period) for
a month is zero, enter “0.” An employee should be counted as a
full-time employee for a month if the employee satisfied the
definition of full-time employee under the monthly measurement
method or the look-back measurement method (as applicable)
on any day of the month. See Full-time employee and Limited
Non-Assessment Period in the Definitions section. Be sure to
use the section 4980H definition and not any other definition of
the term full-time employee that you may use for other purposes.

Part IV—Other ALE Members of
Aggregated ALE Group (Lines 36–65)

An ALE Member must complete this section if it checks “Yes” on
line 21. If the ALE Member was a member of an Aggregated ALE
Group (with other ALE Members) for any month of the calendar
year, enter the name(s) and EIN(s) of up to 30 of the other

Example. Employer uses the look-back measurement
method to determine the full-time status of its employees.
Employee, who is not in a Limited Non-Assessment Period,
averaged over 130 hours of service per month during the
Instructions for Forms 1094-C and 1095-C (2016)

-9-

Part II—Employee Offer of Coverage

Aggregated ALE Group members (not including the reporting
ALE Member). If there are more than 30 members of the
Aggregated ALE Group (not including the reporting ALE
Member), enter the 30 with the highest monthly average number
of full-time employees (using the number reported in Part III,
column (b), if a number was required to be reported) for the year
or for the number of months during which the ALE Member was
a member of the Aggregated ALE Group. If any member of the
Aggregated ALE Group uses the 98% Offer Method and thus is
not required to identify which employees are full-time
employees, all ALE Members of the Aggregated ALE Group
should use the monthly average number of total employees
rather than the monthly average number of full-time employees
for this purpose. Regardless of the number of members in the
Aggregated ALE Group, list only the 30 members in descending
order, listing first the member with the highest average monthly
number of full-time employees (or highest average number of
total employees, if any member of the Aggregated ALE Group
uses the 98% Offer Method), but do not include the reporting
ALE Member. The reporting ALE Member must also complete
Part III, column (d), to indicate which months it was part of an
Aggregated ALE Group.

Plan Start Month. This box is optional for the 2016 Form
1095-C and the ALE Member may leave it blank; it is anticipated
that this box will be mandatory for the 2017 Form 1095-C. To
complete the box, enter the two-digit number (01 through 12)
indicating the calendar month during which the plan year begins
of the health plan in which the employee is offered coverage (or
would be offered coverage if the employee were eligible to
participate in the plan). If more than one plan year could apply
(for instance, if the ALE Member changes the plan year during
the year), enter the earliest applicable month. If there is no
health plan under which coverage is offered to the employee,
enter “00.”
Line 14. For each calendar month, enter the applicable code
from Code Series 1. If the same code applies for all 12 calendar
months, you may enter the applicable code in the “All 12
Months” box and not complete the individual calendar month
boxes, or you may enter the code in each of the boxes for the 12
calendar months. If an employee was not offered coverage for a
month, enter code 1H. Do not leave line 14 blank for any month
(including months when the individual was not an employee of
the ALE Member). An ALE Member offers health coverage for a
month only if it offers health coverage that would provide
coverage for every day of that calendar month. Thus, if coverage
terminates before the last day of the month (because, for
instance, the employee terminates employment with the ALE
Member, or otherwise loses eligibility for coverage under the
plan), the employee does not actually have an offer of coverage
for that month (and code 1H should therefore be entered on
line 14). See line 16, code 2B, later, for how the ALE Member
may complete line 16 in the event that coverage terminates
before the last day of the month.
A code must be entered for each calendar month January
through December, even if the employee was not a full-time
employee for one or more of the calendar months. Enter the
code identifying the type of health coverage actually offered by
the ALE Member (or on behalf of the ALE Member) to the
employee, if any. Do not enter a code for any other type of health
coverage the ALE Member is treated as having offered (but the
employee was not actually offered coverage). For example, do
not enter a code for health coverage the ALE Member is treated
as having offered (but did not actually offer) under the
dependent coverage transition relief, even if the employee is
included in the count of full-time employees offered minimum
essential coverage for purposes of Form 1094-C, Part III, column
(a). See 4980H Transition Relief for 2015 Plan Years for a
discussion of the application of the dependent coverage
transition relief in 2016. If the employee was not actually offered
coverage, enter code 1H (no offer of coverage) on line 14.
For reporting offers of coverage for 2016, an ALE Member
relying on the multiemployer arrangement interim guidance
should enter code 1H on line 14 for any month for which the ALE
Member enters code 2E on line 16 (indicating that the ALE
Member was required to contribute to a multiemployer plan on
behalf of the employee for that month and therefore is eligible for
multiemployer interim rule relief). For a description of the
multiemployer arrangement interim guidance, see Offer of health
coverage in the Definitions section. For reporting for 2016, code
1H may be entered without regard to whether the employee was
eligible to enroll or enrolled in coverage under the multiemployer
plan. For reporting for 2017 and future years, ALE Members
relying on the multiemployer arrangement interim guidance may
be required to report offers of coverage made through a
multiemployer plan in a different manner.

If you are filing Form 1094-C, a valid EIN is required at

TIP the time it is filed. If a valid EIN is not provided, Form

1094-C will not be processed. 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 to the IRS. See the Instructions for Form SS-4 and Pub.
1635.

Specific Instructions for Form 1095-C
Part I—Employee
Line 1. Enter the name of the employee (first name, middle
initial, last name).
Line 2. Enter the 9-digit SSN of the employee (including the
dashes).
Lines 3–6. Enter the employee’s complete address, including
apartment no., if applicable. A country code is not required for
U.S. addresses.

Part I—Applicable Large Employer Member
(Employer)
Line 7. Enter the name of the ALE Member.
Line 8. Enter the ALE Member’s EIN. Do not enter an SSN.
Enter the 9-digit EIN including the dash. The ALE Member’s
name and EIN should match the name and EIN of the ALE
Member reported on lines 1 and 2 of Form 1094-C.
If you are filing Form 1095-C, a valid EIN is required at
the time it is filed. If a valid EIN is not provided, Form
CAUTION 1095-C will not be processed. 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 to the IRS. See the Instructions for Form SS-4 and Pub.
1635.

!

Lines 9 and 11–13. Enter the ALE Member’s complete address
(including room or suite no., if applicable). This address should
match the address reported on lines 3–6 of the Form 1094-C.
Line 10. Enter the telephone number of the person to contact
whom the recipient may call about the information reported on
the form. This may be different than the contact information
entered on line 8 of Form 1094-C.

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Instructions for Forms 1094-C and 1095-C (2016)

receives an offer of COBRA continuation coverage (or an offer of
similar coverage that is made at the same time as the offer of
COBRA continuation coverage is made to enrolled individuals).
Generally, an offer of COBRA continuation coverage is required
to be made only to individuals who were enrolled in coverage
and would lose eligibility for coverage due to the COBRA
qualifying event, but an ALE Member may choose to extend a
similar offer of coverage to a spouse or dependent even if the
offer is not required by COBRA.

Indicator Codes for Employee Offer of Coverage
(Form 1095-C, Line 14)
Code Series 1— Offer of Coverage. The Code Series 1
indicator codes specify the type of coverage, if any, offered to an
employee, the employee’s spouse, and the employee’s
dependents. The term “dependent” has the specific meaning set
forth in the Definitions section of these instructions. In addition,
for this purpose an offer of coverage is treated as made to an
employee’s dependents only if the offer of coverage is made to
an unlimited number of dependents regardless of the actual
number of dependents, if any, an employee has during any
particular calendar month.
If the type of coverage, if any, offered to an employee was the
same for all 12 months in the calendar year, enter the Code
Series 1 indicator code corresponding to the type of coverage
offered either in the “All 12 Months” box or in each of the 12
boxes for the calendar months.
Conditional offer of spousal coverage. New codes 1J and
1K address conditional offers of spousal coverage (also referred
to as coverage offered conditionally). A conditional offer is an
offer of coverage that is subject to one or more reasonable,
objective conditions (for example, an offer to cover an
employee’s spouse only if the spouse is not eligible for coverage
under Medicare or a group health plan sponsored by another
employer). Using new codes 1J and 1K, an ALE Member may
report a conditional offer to a spouse as an offer of coverage,
regardless of whether the spouse meets the reasonable,
objective condition. A conditional offer generally would impact a
spouse’s eligibility for the premium tax credit under section 36B
only if all conditions to the offer are satisfied (that is, the spouse
was actually offered the coverage and eligible for it). To help
employees (and spouses) who have received a conditional offer
determine their eligibility for the premium tax credit, the ALE
Member should be prepared to provide, upon request, a list of
any and all conditions applicable to the spousal offer of
coverage. As is noted in the definition of dependent in the
Definitions section, a spouse is not a dependent for purposes of
section 4980H.
An ALE Member may not report a conditional offer of
coverage to an employee’s dependents as an offer to the
dependents, unless the ALE Member knows that the
dependents met the condition to be eligible for the ALE
Member’s coverage. Further, an offer of coverage is treated as
made to an employee’s dependents only if the offer of coverage
is made to an unlimited number of dependents regardless of the
actual number of dependents, if any, an employee has during
any particular calendar month.
COBRA continuation coverage. An offer of COBRA
continuation coverage is reported differently depending on
whether or not the offer is made due to an employee’s
termination of employment. For more information, see IRS.gov.
An offer of COBRA continuation coverage that is made to a
former employee (or to a former employee’s spouse or
dependents) due to termination of employment should not be
reported as an offer of coverage on line 14. In this situation, code
1H (No offer of coverage) must be entered on line 14 for any
month for which the offer of COBRA continuation coverage
applies, and code 2A (Employee not employed during the
month) must be entered on line 16 (see the instructions for
line 16), without regard to whether the employee or spouse or
dependents enrolled in the COBRA coverage. However, for the
month in which the employee terminates employment with the
ALE Member, see the instructions for line 16, code 2B.
An offer of COBRA continuation coverage that is made to an
employee who remains employed by the ALE Member (or to that
employee’s spouse and dependents) should be reported on
line 14 as an offer of coverage, but only for any individual who
Instructions for Forms 1094-C and 1095-C (2016)

Example. During the applicable open enrollment period for
its health plan, Employer makes an offer of minimum essential
coverage providing minimum value to Employee and to
Employee’s spouse and dependents. Employee elects to enroll
in employee-only coverage starting January 1. On June 1,
Employee experiences a reduction in hours that results in loss of
eligibility for coverage under the plan. As of June 1, Employer
terminates Employee’s existing coverage and makes an offer of
COBRA continuation coverage to Employee, but does not make
an offer to Employee’s spouse and dependents. Employer
should enter code 1E (Minimum essential coverage providing
minimum value offered to employee and at least minimum
essential coverage offered to dependent(s) and spouse) on
line 14 for months January – May, and should enter code 1B
(Minimum essential coverage providing minimum value offered
to employee only) on line 14 for months June – December.
Note. Notwithstanding the preceding instructions for completing
line 14 of Form 1095-C, for purposes of section 4980H, an ALE
Member is treated as having made an offer to the employee’s
dependents for an entire plan year if the ALE Member provided
the employee an effective opportunity to enroll the employee’s
dependents at least once for the plan year, even if the employee
declined to enroll the dependents in the coverage and, as a
result, the dependents later did not receive an offer of COBRA
coverage.
Post-employment (non-COBRA) coverage. An offer of
post-employment coverage to a former employee (or to that
former employee’s spouse or dependent(s)) for coverage that
would be effective after the employee has terminated
employment (such as at retirement) should not be reported as
an offer of coverage on line 14. If the ALE Member is otherwise
required to file Form 1095-C for the former employee (because,
for example, the individual was a full-time employee for one or
more months in the calendar year in which the termination of
employment occurred), the ALE Member should enter code 1H
(no offer of coverage) on line 14 for any month to which an offer
of post-employment coverage applies, and should also enter
code 2A (not an employee) on line 16 (see the instructions for
line 16).
1A. Qualifying Offer: Minimum essential coverage providing
minimum value offered to full-time employee with Employee
Required Contribution equal to or less than 9.5% (as adjusted)
of mainland single federal poverty line and at least minimum
essential coverage offered to spouse and dependent(s).
This code may be used to report for specific months for

TIP which a Qualifying Offer was made, even if the

employee did not receive a Qualifying Offer for all 12
months of the calendar year. However, an ALE Member may not
use the Alternative Furnishing Method for an employee who did
not receive a Qualifying Offer for all 12 calendar months.
1B. Minimum essential coverage providing minimum value
offered to employee only.
1C. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to dependent(s) (not spouse).
1D. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to spouse (not dependent(s)). Do not use code 1D if the
-11-

2 per calendar month. The instructions below address which
code to use for a month if more than one code from Series 2
could apply. If the same code applies for all 12 calendar months,
you may enter the code in the “All 12 Months” box and not
complete the monthly boxes. If none of the codes apply for a
calendar month, leave the line blank for that month.

coverage for the spouse was offered conditionally. Instead use
code 1J.
1E. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
offered to dependent(s) and spouse. Do not use code 1E if the
coverage for the spouse was offered conditionally. Instead use
code 1K.
1F. Minimum essential coverage NOT providing minimum
value offered to employee; employee and spouse or
dependent(s); or employee, spouse and dependents.
1G. Offer of coverage for at least one month of the calendar
year to an individual who was not an employee for any month of
the calendar year or to an employee who was not a full-time
employee for any month of the calendar year (which may include
one or more months in which the individual was not an
employee) and who enrolled in self-insured coverage for one or
more months of the calendar year.

Code Series 2—Section 4980H Safe Harbor Codes and
Other Relief for ALE Members. An ALE Member enters the
applicable Code Series 2 indicator code, if any, on line 16 to
report for one or more months of the calendar year that one of
the following situations applied to the employee.
The employee was not employed or was not a full-time
employee;
The employee enrolled in the minimum essential coverage
offered;
The employee was in a Limited Non-Assessment Period with
respect to section 4980H(b);
The ALE Member met one of the section 4980H affordability
safe harbors with respect to this employee; or
The ALE Member was eligible for multiemployer interim rule
relief for this employee.
If no indicator code applies, leave line 16 blank. In some
circumstances more than one indicator code could apply to the
same employee in the same month. For example, an employee
could be enrolled in health coverage for a particular month
during which he or she is not a full-time employee. However,
only one code may be used for a particular calendar month. For
any month in which an employee enrolled in minimum essential
coverage, in general, indicator code 2C reporting enrollment is
used instead of any other indicator code that could also apply
(but see the exceptions to this rule below, regarding the
multiemployer interim rule relief and enrollment in COBRA
continuation coverage or other post-employment coverage). For
an employee who did not enroll in health coverage, there are
some specific ordering rules for which code to use. See the
descriptions of the codes.
2A. Employee not employed during the month. Enter code 2A
if the employee was not employed on any day of the calendar
month. Do not use code 2A for a month if the individual was an
employee of the ALE Member on any day of the calendar month.
Do not use code 2A for the month during which an employee
terminates employment with the ALE Member.
2B. Employee not a full-time employee. Enter code 2B if the
employee is not a full-time employee for the month and did not
enroll in minimum essential coverage, if offered for the month.
Enter code 2B also if the employee is a full-time employee for
the month and whose offer of coverage (or coverage if the
employee was enrolled) ended before the last day of the month
solely because the employee terminated employment during the
month (so that the offer of coverage or coverage would have
continued if the employee had not terminated employment
during the month).
2C. Employee enrolled in health coverage offered. Enter code
2C for any month in which the employee enrolled for each day of
the month in health coverage offered by the ALE Member,
regardless of whether any other code in Code Series 2 might
also apply (for example, the code for a section 4980H
affordability safe harbor) except as provided below. Do not enter
code 2C in line 16 for any month in which the multiemployer
interim rule relief applies (enter code 2E). Do not enter code 2C
in line 16 if code 1G is entered in line 14. Do not enter code 2C
in line 16 for any month in which a terminated employee is
enrolled in COBRA continuation coverage or other
post-employment coverage (enter code 2A). Do not enter code
2C in line 16 for any month in which the employee enrolled in
coverage that was not minimum essential coverage.
2D. Employee in a section 4980H(b) Limited
Non-Assessment Period. Enter code 2D for any month during
which an employee is in a section 4980H(b) Limited

Note. Code 1G applies for the entire year or not at all.
Therefore, if code 1G applies, an ALE Member must enter code
1G on line 14 in the “All 12 Months” column or in each separate
monthly box (for all 12 months).
1H. No offer of coverage (employee not offered any health
coverage or employee offered coverage that is not minimum
essential coverage, which may include one or more months in
which the individual was not an employee).
1I. Reserved.
1J. Minimum essential coverage providing minimum value
offered to employee and at least minimum essential coverage
conditionally offered to spouse; minimum essential coverage not
offered to dependent(s). (See Conditional offer of spousal
coverage, above, for an additional description of conditional
offers.)
1K. Minimum essential coverage providing minimum value
offered to employee; at least minimum essential coverage
offered to dependents; and at least minimum essential coverage
conditionally offered to spouse. (See Conditional offer of spousal
coverage, above, for an additional description of conditional
offers.)
Line 15. Complete line 15 only if code 1B, 1C, 1D, 1E, 1J, or 1K
is entered on line 14 either in the “All 12 Months” box or in any of
the monthly boxes. Enter the amount of the Employee Required
Contribution, which is, generally, the employee share of the
monthly cost for the lowest-cost self-only minimum essential
coverage providing minimum value that is offered to the
employee. For additional details on how to determine the
Employee Required Contribution, see the Definitions section,
later. Enter the amount including any cents. If the employee is
offered coverage but the Employee Required Contribution is
zero, enter “0.00” (do not leave blank). If the Employee Required
Contribution was the same amount for all 12 calendar months,
you may enter that monthly amount in the “All 12 Months” box
and not complete the monthly boxes. If the Employee Required
Contribution was not the same for all 12 months (for instance, if
an ALE Member has a non-calendar year plan and the employee
share of the premium changes with the new plan year that starts
in 2016), enter the amount in each calendar month for which the
employee was offered minimum value coverage. See the
definition of Employee Required Contribution in the Definitions
section, for more information, including on how to determine the
monthly required contribution from annual data.
For line 15, the amount entered might not be the amount

TIP the employee is paying for the coverage, for example, if

the employee chose to enroll in more expensive
coverage such as family coverage or if the employee is eligible
for certain other healthcare arrangements.

Line 16. For each calendar month, enter the applicable code, if
any, from Code Series 2. Enter only one code from Code Series
-12-

Instructions for Forms 1094-C and 1095-C (2016)

An ALE Member with a self-insured major medical plan and a
health reimbursement arrangement (HRA) that has an individual
who enrolls in both types of minimum essential coverage is
required to report the individual’s coverage under only one of the
arrangements in Part III. An ALE Member with an insured major
medical plan and an HRA that has an individual who enrolls in
both types of minimum essential coverage is not required to
report in Part III the HRA coverage of an individual if the
individual is eligible for the HRA because the individual enrolled
in the insured major medical plan. An ALE Member with an HRA
must report coverage under the HRA in Part III for any individual
who is not enrolled in a major medical plan of the ALE Member
(for example, if the individual is enrolled in a group health plan of
another employer (such as spousal coverage)). For additional
information on the reporting of supplemental coverage, see
Proposed Regulations section 1.6055-1(d)(2) and (3).

Non-Assessment Period. If an employee is in an initial
measurement period, enter code 2D (employee in a section
4980H(b) Limited Non-Assessment Period) for the month, and
not code 2B (employee not a full-time employee). For an
employee in a section 4980H(b) Limited Non-Assessment
Period for whom the ALE Member is also eligible for the
multiemployer interim rule relief for the month, enter code 2E
(multiemployer interim rule relief) and not code 2D (employee in
a section 4980H(b) Limited Non-Assessment Period).
2E. Multiemployer interim rule relief. Enter code 2E for any
month for which the multiemployer arrangement interim
guidance applies for that employee, regardless of whether any
other code in Code Series 2 (including code 2C) might also
apply. This relief is described under Offer of Health Coverage in
the Definitions section of these instructions.
Note. Although ALE Members may use the section 4980H
affordability safe harbors to determine affordability for purposes
of the multiemployer arrangement interim guidance, an ALE
Member eligible for the relief provided in the multiemployer
arrangement interim guidance for a month for an employee
should enter code 2E (multiemployer interim rule relief), and not
codes 2F, 2G, or 2H (codes for section 4980H affordability safe
harbors).
2F. Section 4980H affordability Form W-2 safe harbor. Enter
code 2F if the ALE Member used the section 4980H Form W-2
safe harbor to determine affordability for purposes of section
4980H(b) for this employee for the year. If an ALE Member uses
this safe harbor for an employee, it must be used for all months
of the calendar year for which the employee is offered health
coverage.
2G. Section 4980H affordability federal poverty line safe
harbor. Enter code 2G if the ALE Member used the section
4980H federal poverty line safe harbor to determine affordability
for purposes of section 4980H(b) for this employee for any
month(s).
2H. Section 4980H affordability rate of pay safe harbor. Enter
code 2H if the ALE Member used the section 4980H rate of pay
safe harbor to determine affordability for purposes of section
4980H(b) for this employee for any month(s).

If the ALE Member is completing Part III, enter “X” in the
check box in Part III. If the ALE Member is not completing Part III,
do not enter “X” in the check box in Part III.
This part must be completed by an ALE Member offering
self-insured health coverage for any individual who was an
employee for one or more calendar months of the year, whether
full-time or non-full-time, and who enrolled in the coverage. The
employee (if enrolled in self-insured coverage) should be listed
on line 17; any other family members who enrolled in coverage
offered to the employee should be listed on subsequent lines.
All employee family members that are covered

TIP individuals through the employee’s enrollment (for

example, because the employee elected family
coverage) must be included on the same form as the employee
(or any other individual to whom the offer was made). For
example, if the employee is offered family coverage by his or her
employer under a self-insured health plan and enrolls in the
family coverage, the employee and the employee’s family
members that are covered under the plan must all be reported
on the same Form 1095-C.
If two or more employees employed by the same ALE
Member are spouses or an employee and his or her dependent,
and one employee enrolled in a coverage option under the plan
that also covered the other employee(s) (for example, one
employee spouse enrolled in family coverage that provided
coverage to the other employee spouse and their employee
dependent child), the enrollment information should be reflected
only on Form 1095-C for the employee who enrolled in the
coverage. (However, it would report the other employee family
members as covered individuals).

Note. An affordability safe harbor code should not be entered
on line 16 for any month that the ALE member did not offer
minimum essential coverage to at least 95% of its full-time
employees and their dependents (that is, any month for which
the ALE member checked the “No” box on Form 1094-C, Part III,
column (a)). For more information, see the instructions for Form
1094-C, Part III, column (a).
2I. Reserved.
Note. References to 9.5% in the section 4980H affordability
safe harbors and Qualifying Offer Method are applied based on
the percentage as indexed for purposes of applying the
affordability thresholds under section 36B (the premium tax
credit). The percentage, as adjusted, is 9.56% for plan years
beginning in 2015, and 9.66% for plan years beginning in 2016.
See Notice 2015-87, Q&A 12, at www.irs.gov/irb/2015-52_IRB/
ar11.html.

Coverage of Non-Employee. This part may be completed by
an ALE Member offering self-insured health coverage for any
other individual who enrolled in the coverage under the plan for
one or more calendar months of the year but was not an
employee for any calendar month of the year, such as a
non-employee director, a retired employee who retired in a
previous year, a terminated employee receiving COBRA
continuation coverage (or any other form of post-employment
coverage) who terminated employment during a previous year,
and a non-employee COBRA beneficiary (but not including an
individual who obtained coverage through the employee’s
enrollment, such as a spouse or dependent obtaining coverage
when an employee elects COBRA continuation coverage that is
family coverage). If Form 1095-C is used with respect to an
individual who was not an employee for any month of the
calendar year, Part II must be completed by using code 1G in the
“All 12 Months” box or the separate monthly boxes for all 12
calendar months. The employer must report for these individuals
using Form 1095-B, if it chooses not to use Form 1095-C.

Part III—Covered Individuals (Lines 17–22)

Complete Part III ONLY if the ALE Member offers
employer-sponsored self-insured health coverage in which the
employee or other individual enrolled. For this purpose,
employer-sponsored self-insured health coverage does not
include coverage under a multiemployer plan. Do not complete
Part III if the ALE Member offers coverage only under an insured
group health plan. If an ALE Member offers both insured and
self-insured coverage, complete Part III only for employees who
enroll in the self-insured coverage.

Instructions for Forms 1094-C and 1095-C (2016)

-13-

2014-9_IRB/ar05.html and section 6056, T.D. 9661, 2014-13
I.R.B. 855, at www.irs.gov/irb/2014-13_IRB/ar09.html.

If a non-employee individual enrolls in the coverage
TIP under a self-insured health plan, all family members that
are covered individuals because of the individual’s
enrollment must be included on the same Form 1095-B or Form
1095-C as the individual who is offered, and enrolls in, the
coverage.

Aggregated ALE Group. An Aggregated ALE Group refers to
a group of ALE Members treated as a single employer under
section 414(b), 414(c), 414(m), or 414(o). An ALE Member is a
member of an Aggregated ALE Group for a month if it is treated
as a single employer with the other members of the group on any
day of the calendar month. If an ALE is made up of only one
person or entity, that one ALE Member is not a part of an
Aggregated ALE Group. Government entities and churches or
conventions or associations of churches may apply a
reasonable, good faith interpretation of the aggregation rules
under section 414 in determining their status as an ALE or
member of an Aggregated ALE Group. For more information on
how the aggregation rules apply to government entity employers,
see Notice 2015–87, Q&A 18, at www.irs.gov/irb/2015–52_IRB/
ar11.html.

Columns (a) through (e), as applicable, must be completed
for each individual enrolled in the coverage, including the
employee reported on line 1. Enter the nine-digit SSN or other
TIN for each covered individual in column (b). Enter a date of
birth in column (c) only if an SSN or other TIN 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, complete this information on the
additional covered individuals on Part III Covered Individuals —
Continuation Sheet(s). Do not count the continuation sheet(s) as
additional Forms 1095-C in the count of forms submitted with the
accompanying Form 1094-C.

Applicable Large Employer (ALE). An ALE is, for a particular
calendar year, any single employer, or group of employers
treated as an Aggregated ALE Group, that employed an average
of at least 50 full-time employees (including full-time equivalent
employees) on business days during the preceding calendar
year. For purposes of determining an employer’s average
number of employees, disregard an employee for any month in
which the employee has coverage under a plan described in
section 4980H(c)(2)(F) (generally, TRICARE or Veterans
Administration coverage). A new employer (that is, an employer
that was not in existence on any business day in the prior
calendar year) is an ALE for the current calendar year if it
reasonably expects to employ, and actually does employ, an
average of at least 50 full-time employees (including full-time
equivalent employees) on business days during the current
calendar year. For information on a special rule for certain
employers with seasonal workers, see the final regulations under
section 4980H and FAQs on IRS.gov.

Governmental Unit employers offering self-insured

TIP health coverage that have delegated another

governmental unit (DGE) for purposes of reporting and
furnishing enrollment information (meaning the information that
otherwise would be reported on Form 1095-C, Part III), but have
not designated a DGE for purposes of reporting and furnishing
offer of coverage information (meaning the information that is
reported on Form 1095-C, Part II), should file and furnish Forms
1095-C with a completed Part I and Part II, but not a completed
Part III, and should not check the box indicating that the
Governmental Unit offers self-insured health coverage. In
this case, the DGE should file Forms 1094-B and 1095-B to
report enrollment information for employees on behalf of the
Governmental Unit. See FAQs on IRS.gov.

Applicable Large Employer Member (ALE Member). An
ALE Member is a single person or entity that is an ALE, or if
applicable, each person or entity that is a member of an
Aggregated ALE Group. A person or entity that does not have
employees or only has employees with no hours of service (for
example, only employees whose entire service consists of work
outside of the United States that does not count as hours of
service under section 4980H) is not an ALE Member.

A DGE that has been delegated by a Governmental Unit for
purposes of reporting and furnishing both offer of coverage and
enrollment information (meaning the information that would be
reported on Parts II and III of Form 1095-C) should file Forms
1094-C and 1095-C to report the information for employees on
behalf of the Governmental Unit.

Bona fide volunteer. A bona fide volunteer is an employee of
a government entity or tax-exempt organization whose only
compensation from that entity or organization is (1)
reimbursement for (or reasonable allowance for) reasonable
expenses incurred in the performance of services by volunteers,
or (2) reasonable benefits (including length of service awards),
and nominal fees, customarily paid by similar entities in
connection with the performance of services by volunteers.

Column (a). Enter the name of each covered individual
(including the employee, if the employee is enrolled in
self-insured coverage).
Column (b). Enter the 9-digit SSN for each covered individual,
including the dashes. For covered individuals who are not the
employee listed in Part I, a taxpayer identification number (TIN),
rather than an SSN, may be entered if the covered individual
does not have an SSN, or the field may be left blank if the
covered individual does not have a TIN.

COBRA continuation coverage. COBRA continuation
coverage is health coverage that is required to be offered under
the Consolidated Omnibus Budget Reconciliation Act of 1986
(COBRA) in certain circumstances in which an employee or
other individual covered under a health plan loses eligibility for
coverage under that health plan (for example, because the
employee terminates employment or has a reduction in hours).
For purposes of these instructions, COBRA continuation
coverage also includes coverage required under any other
federal or state law that provides continuation coverage
comparable to that provided under COBRA. For additional
details, see section 4980B and Regulations sections 54.4980B-1
through 54.4980B-10.

Column (c). Enter a date of birth (YYYY-MM-DD) 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.
Column (e). If the individual was not covered for all 12 months
of the calendar year, check the applicable box(es) for the
month(s) in which the individual was covered for at least one day
in the month.

Definitions

This section contains the definitions of key terms used in Forms
1094-C and 1095-C and these instructions. For definitions of
terms not included in this section, see the final regulations under
section 4980H, T.D. 9655, 2014-9 I.R.B. 541, at www.irs.gov/irb/

Dependent. A dependent is an employee’s child, including a
child who has been legally adopted or legally placed for adoption
with the employee, who has not reached age 26. A child reaches
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Instructions for Forms 1094-C and 1095-C (2016)

age 26 on the 26th anniversary of the date the child was born
and is treated as a dependent for the entire calendar month
during which he or she reaches age 26. For this purpose, a
dependent does not include stepchildren, foster children, or a
child that does not reside in the United States (or a country
contiguous to the United States) and who is not a United States
citizen or national. For this purpose, a dependent does not
include a spouse.

Employee Required Contribution. The Employee Required
Contribution is the employee’s share of the monthly cost for the
lowest-cost self-only minimum essential coverage providing
minimum value that is offered to the employee by the ALE
Member. The employee share is the portion of the monthly cost
that would be paid by the employee for self-only coverage,
whether paid through salary reduction or otherwise.
For purposes of determining the amount of the employee’s
share of the monthly cost, an ALE Member may divide the total
cost to the employee for the plan year by the number of months
in the plan year. This monthly amount of the employee’s share of
the cost would then be reported for any months of that plan year
that fall within the 2016 calendar year. For example, if the plan
year begins January 1, the ALE Member may determine the
amount to report for each month by taking the total annual
employee cost for all 12 months and dividing by 12. If the plan
year begins April 1, the ALE Member may determine the amount
to report for January through March, 2016, by taking the total
annual employee cost for the plan year ending March 31, 2016,
and dividing by 12 (and reporting that amount for January,
February, and March 2016). Then the ALE Member may
determine the monthly amount for April through December, 2016
by taking the total annual employee cost for the plan year ending
March 31, 2017, and dividing by 12 (and reporting that amount
for April through December 2016).
The Employee Required Contribution may not be the amount
the employee paid for coverage. For additional rules on
determining the amount of the Employee Required Contribution,
including for cases in which an ALE Member makes available
certain HRA contributions, cafeteria plan contributions, wellness
program incentives, and opt-out payments, see Regulations
sections1.5000A-3(e)(3)(ii) and 1.36B-2(c)(3)(v)(A). Also see
Notice 2015-87.

Designated Governmental Entity (DGE). A DGE is a person
or persons that are part of or related to the Governmental Unit
that is the ALE Member and that is appropriately designated for
purposes of these reporting requirements. For a Governmental
Unit that has delegated some or all of its reporting
responsibilities to a DGE for some or all of its employees, one
Authoritative Transmittal must still be filed for that Governmental
Unit reporting aggregate employer-level data for all employees
of the Governmental Unit (including those for whom the
Governmental Unit has delegated its reporting responsibilities).
For more information, see Authoritative Transmittal for
Employers Filing Multiple Forms 1094-C.
Eligible Employer-Sponsored Plan. An eligible
employer-sponsored plan refers to group health coverage for
employees under (1) a governmental plan, such as the Federal
Employees Health Benefits Program (FEHB), (2) an insured plan
or coverage offered in the small or large group market within a
state, (3) a grandfathered health plan offered in a group market,
or (4) a self-insured group health plan for employees.
Employee. An employee is an individual who is an employee
under the common-law standard for determining
employer-employee relationships. An employee does not
include a sole proprietor, a partner in a partnership, an S
corporation shareholder who owns at least 2-percent of the S
corporation, a leased employee within the meaning of section
414(n), or a worker that is a qualified real estate agent or direct
seller.
If an employee is an employee of more than one ALE
Member of the same Aggregated ALE Group during a calendar
month, the employee is treated as an employee of the ALE
Member for whom the employee has the greatest number of
hours of service for that calendar month; if the employee has an
equal number of hours of service for two or more ALE Members
of the same Aggregated ALE Group for the calendar month,
those ALE Members must treat one of the ALE Members as the
employer of that employee for that calendar month. See One
Form 1095-C for Each Employee of Each Employer for a
discussion of reporting in these circumstances. See Pub.15-A,
Employer’s Supplemental Tax Guide, for more information on
determining who is an employee.
Note. In certain circumstances, an employee may have a
break in service (including a break in service due to a
termination of employment) during which the individual does not
earn hours of service, but upon beginning to earn hours of
service again the ALE Member must treat the individual as a
continuing employee rather than a new hire for purposes of
certain rules under the regulations under section 4980H. See
Regulations sections 54.4980H-3(c)(4) and 54.4980H-3(d)(6).
These rules do not impact whether the individual was an
employee during the break in service, so the individual should
only be treated as an employee during the break in service for
purposes of reporting if the individual remained an employee
during that period (and had not terminated employment with the
ALE Member). For example, an employee on unpaid leave
during the break in service would be treated as an employee for
reporting purposes during the break in service, while a former
employee whose employment had been terminated during the
break in service would not be treated as an employee for
reporting purposes.
Instructions for Forms 1094-C and 1095-C (2016)

Employer. For purposes of these instructions, an employer is
the person that is the employer of an employee under the
common-law standard for determining employer-employee
relationships and that is subject to the employer shared
responsibility provisions of section 4980H (these employers are
referred to as ALE Members). For more information on which
employers are ALE Members, see the definitions of Applicable
Large Employer (ALE) and Applicable Large Employer Member
(ALE Member).
Full-time employee. For purposes of Forms 1094-C and
1095-C, the term “full-time employee” means a full-time
employee as defined under section 4980H and the related
regulations, rather than any other definition of that term that the
ALE Member may use for other purposes. Accordingly, a
full-time employee is an employee who, for a calendar month, is
determined to be a full-time employee under either the monthly
measurement method or the look-back measurement method
(as applicable to that employee). The monthly measurement
method and the look-back measurement method are the two
methods provided under the section 4980H regulations for
determining whether an employee has sufficient hours of service
to be a full-time employee. Under the monthly measurement
method, a full-time employee is an employee who was employed
an average of at least 30 hours of service per week with the ALE
Member during a calendar month. Under the look-back
measurement method, an employee is a full-time employee for
each month of the stability period selected by the ALE Member if
the employee was employed an average of least 30 hours of
service per week with the ALE Member during the measurement
period preceding that stability period. (The look-back
measurement method for identifying full-time employees is
available only for purposes of determining and computing liability
under section 4980H, and not for purposes of determining if the
employer is an Applicable Large Employer.) For purposes of
both methods, 130 hours of service in a calendar month is
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tax-exempt entity, as part of a Federal Work-Study Program (or
a substantially similar program of a State or political subdivision
thereof) or to the extent the compensation for services
performed constitutes income from sources outside the United
States. For additional rules for determining hours of service, see
Regulations sections 54.4980H-1(a)(24), 54.4980H-3(b) and
Notice 2015–87, Q&A 14, at www.irs.gov/irb/2015–52_IRB/
ar11.html. See section VI of the preamble to the section 4980H
regulations for a discussion of determination of hours of service
for categories of employees for whom the general rules for
determining hours of service may present special difficulties
(including adjunct faculty and commissioned salespeople) and
certain categories of work hours associated with some positions
of employment, including layover hours (for example, for certain
airline employees), on-call hours, and work performed by an
individual who is subject to a vow of poverty as a member of a
religious order.

treated as the monthly equivalent of at least 30 hours of service
per week.
An ALE Member must report complete information for all 12
months of the calendar year for any of its employees who were
full-time employees for one or more months of the calendar year.
For more information on the identification of full-time employees,
including discussion of the monthly measurement method and
the look-back measurement method, and the rules for when an
ALE Member may use one or both methods, see Regulations
sections 54.4980H-1(a)(21) and 54.4980H-3 and Notice
2014-49, 2014-41 I.R.B. 66 (describing a proposed approach to
the application of the look-back measurement method in
situations in which the measurement period applicable to an
employee changes).
Note. A former employee (for example, a retiree) is not a
full-time employee for any month after termination of
employment with the ALE Member. However, if the former
employee was a full-time employee for any month of the
calendar year (for example, before retiring mid-year), the ALE
Member must complete information in Part II of Form 1095-C for
all 12 months of the calendar year, using the appropriate codes.

Limited Non-Assessment Period. A Limited Non-Assessment
Period generally refers to a period during which an ALE Member
will not be subject to an assessable payment under section
4980H(a), and in certain cases section 4980H(b), for a full-time
employee, regardless of whether that employee is offered health
coverage during that period.
The first five periods described below are Limited
Non-Assessment Periods with respect to sections 4980H(a) and
4980H(b) only if the employee is offered health coverage by the
first day of the first month following the end of the period. Also,
the first five periods described below are Limited
Non-Assessment Periods for section 4980H(b) only if the health
coverage that is offered at the end of the period provides
minimum value. For more information on Limited
Non-Assessment Periods and the application of section 4980H,
see Regulations section 54.4980H-1(a)(26).
First Year as ALE Period. January through March of the first
calendar year in which an employer is an ALE, but only for an
employee who was not offered health coverage by the employer
at any point during the prior calendar year.
Waiting Period under the Monthly Measurement Method. If an
ALE Member is using the monthly measurement method to
determine whether an employee is a full-time employee, the
period beginning with the first full calendar month in which the
employee is first otherwise (but for completion of the waiting
period) eligible for an offer of health coverage and ending no
later than two full calendar months after the end of that first
calendar month.
Waiting Period under the Look-Back Measurement Method. If
an ALE Member is using the look-back measurement method to
determine whether an employee is a full-time employee and the
employee is reasonably expected to be a full-time employee at
his or her start date, the period beginning on the employee’s
start date and ending not later than the end of the employee’s
third full calendar month of employment.
Initial Measurement Period and Associated Administrative
Period under the Look-Back Measurement Method. If an ALE
Member is using the look-back measurement method to
determine whether a new employee is a full-time employee, and
the employee is a variable hour employee, seasonal employee
or part-time employee, the initial measurement period for that
employee and the administrative period immediately following
the end of that initial measurement period.
Period Following Change in Status that Occurs During Initial
Measurement Period Under the Look-Back Measurement
Method. If an ALE Member is using the look-back measurement
method to determine whether a new employee is a full-time
employee, and, as of the employee’s start date, the employee is
a variable hour employee, seasonal employee or part-time
employee, but, during the initial measurement period, the
employee has a change in employment status such that, if the
employee had begun employment in the new position or status,

An ALE Member need not file a Form 1095-C for an

TIP individual who for each month of a calendar year is

either not an employee of the ALE Member or is an
employee in a Limited Non-Assessment Period with respect to
section 4980H(b). However, for the months in which the
employee was an employee of the ALE Member, such an
employee would be included in the total employee count
reported on Form 1094-C, Part III, column (c). Also, if during the
Limited Non-Assessment Period the employee enrolled in
coverage under a self-insured employer-sponsored plan, the
ALE Member must file a Form 1095-C for the employee to report
coverage information for the year.
Full-time equivalent employees. A combination of
employees, each of whom individually is not treated as a
full-time employee because he or she is not employed on
average at least 30 hours of service per week with an employer,
but who, in combination, are counted as the equivalent of a
full-time employee solely for purposes of determining whether
the employer is an ALE. For rules on how to determine full-time
equivalent employees, see Regulations section 54.4980H-2(c).
Governmental Unit and Agency or Instrumentality of a
Governmental Unit. A Governmental Unit is the government of
the United States, any State or political subdivision thereof, or
any Indian tribal government (as defined in section 7701(a)(40))
or subdivision of an Indian tribal government (as defined in
section 7871(d)). For purposes of these instructions, references
to a Governmental Unit include an Agency or Instrumentality of a
Governmental Unit. Until guidance is issued that defines the
term Agency or Instrumentality of a Governmental Unit for
purposes of section 6056, an entity may determine whether it is
an Agency or Instrumentality of a Governmental Unit based on a
reasonable and good faith interpretation of existing rules relating
to agency or instrumentality determinations for other federal tax
purposes.
Health coverage. As used in these instructions, health
coverage refers to minimum essential coverage, unless
otherwise indicated.
Hours of service. An hour of service is each hour for which an
employee is paid, or entitled to payment, for the performance of
duties for the employer, and each hour for which an employee is
paid, or entitled to payment, for a period of time during which no
duties are performed due to vacation, holiday, illness, incapacity
(including disability), layoff, jury duty, military duty, or leave of
absence. An hour of service does not include any hour of service
performed as a bona fide volunteer of a government entity or
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Instructions for Forms 1094-C and 1095-C (2016)

coverage is treated as made to an employee’s dependents only
if the offer of coverage is made to an unlimited number of
dependents regardless of the actual number of dependents, if
any, an employee has during any particular calendar month.
An ALE Member offers health coverage for a month only if it
offers health coverage that would provide coverage for every
day of that calendar month. For reporting purposes, this means
that an offer of coverage does not occur for a month if an
employee’s employment terminates before the last day of a
calendar month and the health coverage also ends before the
last day of that calendar month (or for an employee who did not
enroll in coverage, the coverage would have ended if the
employee had enrolled in coverage). However, see the
description of Code Series 2—Section 4980H Safe Harbor
Codes and Other Relief for Employers, code 2B which may be
applicable in these circumstances to indicate that the ALE
Member is treated as having offered coverage for the entire
month for purposes of section 4980H.
An ALE Member offers health coverage to an employee if it,
or another employer in the Aggregated ALE Group, or a third
party such as a multiemployer or single employer Taft-Hartley
plan, a multiple employer welfare arrangement (MEWA), or, in
certain cases, a staffing firm, offers health coverage on behalf of
the employer. See Regulations sections 54.4980H-4(b)(2) and
54.4980H-5(b).

the employee would have reasonably been expected to be a
full-time employee, the period beginning on the date of the
employee’s change in employment status and ending not later
than the end of the third full calendar month following the change
in employment status. If the employee is a full-time employee
based on the initial measurement period and the associated
stability period starts sooner than the end of the third full
calendar month following the change in employment status, this
Limited Non-Assessment Period ends on the day before the first
day of that associated stability period.
First Calendar Month of Employment. If the employee’s first
day of employment is a day other than the first day of the
calendar month, then the employee’s first calendar month of
employment is a Limited Non-Assessment Period.
Minimum essential coverage (MEC). Although various types
of health coverage may qualify as minimum essential coverage,
for purposes of these instructions, minimum essential coverage
refers to health coverage under an eligible employer-sponsored
plan. For more details on minimum essential coverage, see
Minimum essential coverage in Pub. 974.
Minimum value. A plan provides minimum value if the plan
pays at least 60% of the costs of benefits for a standard
population and provides substantial coverage of inpatient
hospitalization services and physician services. An offer of
coverage under a plan that fails to provide substantial coverage
of inpatient hospitalization and physician services should be
reported on Form 1095-C as not providing minimum value, even
if an employer qualifies for the section 4980H transition rule
under Notice 2014-69, 2014-48 I.R.B. 903 at www.irs.gov/irb/
2014-48_IRB/ar07.html.

Interim Guidance Regarding Multiemployer

TIP Arrangements. An ALE Member is treated as offering

health coverage to an employee if the ALE Member is
required by a collective bargaining agreement or related
participation agreement to make contributions for that employee
to a multiemployer plan that offers, to individuals who satisfy the
plan’s eligibility conditions, health coverage that is affordable
and provides minimum value, and that also offers health
coverage to those individuals’ dependents (or is eligible for the
section 4980H transition relief regarding offers of coverage to
dependents, if applicable for certain calendar months in 2016.
See Section 4980H Transition Relief for 2015 Plan Years). For
more information, see section XV.E of the preamble to the final
regulations under section 4980H. This relief is referred to as the
multiemployer arrangement interim guidance and the
multiemployer interim rule relief in these instructions.

Offer of health coverage. An ALE Member makes an offer of
coverage to an employee if it provides the employee an effective
opportunity to enroll in the health coverage (or to decline that
coverage) at least once for each plan year. For this purpose, the
plan year must be 12 consecutive months unless a short plan
year of less than 12 consecutive months is permitted for a valid
business purpose. An ALE Member makes an offer of health
coverage to an employee for the plan year if it continues the
employee’s election of coverage from a prior year but provides
the employee an effective opportunity to opt out of the health
coverage. If an ALE Member provides health coverage to an
employee but does not provide the employee an effective
opportunity to decline the coverage, the ALE Member is treated
as having made an offer of health coverage to the employee only
if that health coverage provides minimum value and does not
have an Employee Required Contribution for the coverage for
any calendar month of more than 9.5% (as adjusted) of a
monthly amount determined as the mainland federal poverty line
for a single individual for the applicable calendar year, divided by
12.
For purposes of reporting, an offer to a spouse includes an
offer to a spouse that is subject to one or more reasonable,
objective conditions, regardless of whether the reasonable,
objective conditions are satisfied. For example, an offer of
coverage that is available to a spouse only if the spouse certifies
that the spouse does not have access to health coverage from
another employer is treated as an offer of coverage to the
spouse for reporting purposes. Note that this treatment is for
reporting purposes only, and generally will not affect the
spouse’s eligibility for the premium tax credit if the spouse did
not meet the condition and therefore did not have an actual offer
of coverage. A conditional offer to a spouse is reported by
entering code 1J or 1K (as applicable) on line 14 of Form
1095-C. See the instructions for line 14 for more information. An
offer to a dependent does not include an offer to a dependent
that is subject to one or more reasonable, objective conditions
unless the dependent satisfies the conditions and the dependent
actually had an offer of coverage. In addition, an offer of
Instructions for Forms 1094-C and 1095-C (2016)

Qualifying Offer. A Qualifying Offer is an offer of MEC
providing minimum value to one or more full-time employees for
all calendar months during the calendar year for which the
employee was a full-time employee for whom a section 4980H
assessable payment could apply, with an Employee Required
Contribution for each month not exceeding 9.5 % (as adjusted)
of the mainland single federal poverty line divided by 12,
provided that the offer includes an offer of MEC to the
employee’s spouse and dependents (if any).

Section 4980H Transition
Relief for 2015 Plan Years

Several forms of transition relief under section 4980H were
available to ALE Members for 2015. Only certain of these forms
of transition relief continue to apply in 2016, and they apply only
for certain ALE Members and only for certain calendar months in
2016. This section describes these types of section 4980H
transition relief that continue to apply and how an ALE Member
reports its eligibility for each type of relief.
The transition relief described in this section is solely for the
ALE Member for purposes of section 4980H and does not affect
the employee’s potential eligibility for the premium tax credit.
Accordingly, regardless of whether the ALE Member is eligible
for relief under section 4980H for an employee for one or more
months, the Form 1095-C for that employee must accurately

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or different members in an Aggregated ALE Group, offer
coverage under more than one health plan with different plan
years, the transition relief applies through the last day of the
latest of those plan years, for all ALE Members in the
Aggregated ALE Group, if applicable.
To certify that an employer is eligible for this transition relief it
must have met the following conditions:
The employer is an ALE or is part of an Aggregated ALE
Group that had 50 to 99 full-time employees, including full-time
equivalent employees, on business days in 2014;
During the period of February 9, 2014, through December 31,
2014, the ALE or the Aggregated ALE Group of which the
employer is a member did not reduce the size of its workforce or
reduce the overall hours of service of its employees in order to
qualify for the transition relief; and
During the period of February 9, 2014, through the last day of
the 2015 plan year, the ALE or Aggregated ALE Group of which
the employer is a member does not eliminate or materially
reduce the health coverage, if any, it offered as of February 9,
2014.

report the health coverage offered to that employee (if any)
during that period, including, if applicable, the Employee
Required Contribution. For more details regarding this section
4980H transition relief, see section XV of the preamble to the
final regulations under section 4980H.

2015 Plan Year Section 4980H Transition Relief
Based on Number of Full-Time Employees
(Form 1094-C, Line 22, Box C, and Form 1094-C,
Lines 23-35, Column (e))

An employer may be eligible for one of the two types of 2015
plan year transition relief under section 4980H based on the
employer’s number of full-time employees (and full-time
equivalent employees) if certain conditions described below are
met. One of these two types of 2015 transition relief under
section 4980H is for employers with 50 to 99 full-time employees
and the other type of relief is for employers with 100 or more
full-time employees (in each case including full-time equivalent
employees). Eligibility for this transition relief is reported on Form
1094-C, line 22, box C, and the specific form of relief for which
the employer is eligible must be reported on Form 1094-C, lines
23–35, column (e), using either code A (50-99 Transition Relief)
or code B (100 or more Transition Relief). An employer eligible
for this relief for certain calendar months in 2016 is still subject to
the Forms 1094-C and 1095-C reporting requirements for all
months of 2016, including the calendar months in the 2015 plan
year. For purposes of determining eligibility for either of these
types of section 4980H transition relief, the number of full-time
employees (including full-time equivalent employees) for 2015 is
determined in the same way that an employer determines
whether it is an ALE (including using employment and hours of
service data from 2014) and is calculated for the Aggregated
ALE Group (rather than for each ALE Member).

Example. As of February 9, 2014, Employer A (which is an
ALE with only one ALE Member) sponsors a group health plan
with a plan year that begins April 1 under which 40 of its full-time
employees are offered health coverage that provides minimum
value and with an employer contribution of $300 per month for
employee-only coverage. The offer of health coverage is
affordable for some, but not all, of Employer A’s full-time
employees. During the period from February 9, 2014, through
December 31, 2014, two of Employer A’s employees voluntarily
terminate employment and Employer A terminates three
employees because of the non-renewal of a customer contract
but does not otherwise reduce the size of its workforce or reduce
any employee’s hours of service. If those five employees had
continued in employment throughout 2014, the employer would
have had an average of 100 full-time employees (including
full-time equivalent employees) on business days in 2014.
However, as a result of the terminations, it had an average of
only 97 full-time employees (including full-time equivalent
employees) for business days in 2014. During the period of
February 9, 2014, through March 31, 2016, Employer A does not
change the eligibility requirements for the group health plan
(including not amending it to eliminate its existing health
coverage for dependents) and continues to make an employer
contribution of $300 per month toward the cost of employee-only
coverage that provides minimum value. Employer A certifies in a
timely manner as to its eligibility for the transition relief; Employer
A is eligible for the transition relief for January 2016 through
March 2016.

For the 2016 calendar year, the transition relief described
below (50-99 Transition Relief and 100 or more Transition
Relief) is applicable only if the ALE Member, or any member of
an ALE Member’s Aggregated ALE Group, if applicable, offers
coverage under a health plan with a plan year beginning on a
date other than January 1 (a non-calendar year plan year), and
only with respect to calendar months in 2016 that fall within the
plan year that began in the 2015 calendar year (the 2015 plan
year). If an ALE Member, or different members in an Aggregated
ALE Group, offer coverage under more than one health plan with
different plan years, the transition relief applies through the last
day of the latest of those plan years, for all ALE Members in the
Aggregated ALE Group, if applicable.
Example. Employer A and Employer B are ALE Members in
the same Aggregated ALE Group. Employer A offers coverage
through Health Plan A, with a plan year beginning January 1 and
ending December 31. Employer B offers coverage through
Health Plan B, with a plan year beginning July 1 and ending
June 30. If otherwise eligible for either of the forms of the
transition relief described below (50-99 Transition Relief and 100
or more Transition Relief), both Employer A and Employer B
may rely on that transition relief for the months January through
June 2016 (including with respect to employees who were
offered coverage under Health Plan A but not Health Plan B).

2. 2015 Plan Year Transition Relief for Calculation of Assessable Payments Under Section 4980H(a) for ALEs with
100 or More Full-Time Employees, Including Full-Time
Equivalent Employees (100 or More Transition Relief). This
relief applies for an ALE Member with at least one plan with a
non-calendar year plan year and for an ALE Member that is a
member of an Aggregated ALE Group with at least one plan with
a non-calendar year plan year. For such an ALE Member, for the
calendar months in 2016 that fall within the 2015 plan year, if the
employer is an ALE or is part of an Aggregated ALE Group that
had 100 or more full-time employees (including full-time
equivalent employees) on business days in 2014, and is subject
to an assessable payment under section 4980H(a) for any
month(s) in 2016 that fall within the 2015 plan year, the
assessable payment under section 4980H(a) is calculated by
reducing the ALE Member’s number of full-time employees by
the ALE Member’s allocable share of 80 (rather than by the ALE
Member’s standard allocable share of 30). If an ALE Member, or
different members in an Aggregated ALE Group, offer coverage
under more than one health plan with different plan years, the

1. 2015 Plan Year Section 4980H Transition Relief for ALEs
with Fewer Than 100 Full-Time Employees, Including
Full-Time Equivalent Employees (50-99 Transition Relief).
For an ALE Member with at least one plan with a non-calendar
year plan year or for an ALE Member that is a member of an
Aggregated ALE Group with at least one plan with a
non-calendar year plan year, if the ALE Member is eligible for
this 2015 plan year transition relief, no assessable payment
under section 4980H(a) or (b) will apply for any calendar month
in 2016 that falls within the 2015 plan year. If any ALE Member,
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Instructions for Forms 1094-C and 1095-C (2016)

transition relief applies through the last day of the latest of those
plan years, for all ALE Members in the Aggregated ALE Group, if
applicable.
For the rules on how the 80 employee reduction is allocated
among the employers in an Aggregated ALE Group, see
Regulations section 54.4980H-4(e).

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 sections 6055,
6056, 4980H and their regulations. We request it to confirm that
you are providing your employees offers of, and enrollment in,
health coverage and to determine the employer shared
responsibility payments and eligibility of your employees for
premium tax credits. If you do not provide this information, we
may be unable to determine whether your employees are
entitled to premium tax credits. Providing false or fraudulent
information may subject you to penalties. We may disclose this
information to the Department of Justice for civil or criminal
litigation 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.

2015 Plan Year Section 4980H(a) Transition
Relief if an Offer of Health Coverage is Made to
at least 70 Percent of Full-Time Employees
(Form 1094-C, Lines 23–35, Column (a))

For an ALE Member with at least one plan with a non-calendar
year plan year, for the calendar months in 2016 that fall within
the 2015 plan year, an employer that offers health coverage to at
least 70 % of its full-time employees (and their dependents)
may, on Form 1094-C, lines 23–35, column (a), enter an “X” in
the “Yes” checkbox for the month(s) during which it met that
70-percent threshold, as applicable. If the ALE Member offers
coverage under more than one health plan with different plan
years, the transition relief applies through the last day of the
latest of those plan years.

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.

2015 Plan Year Section 4980H(a) Transition
Relief for Certain Arrangements that do not
Offer Health Coverage for Dependents (Form
1094-C, Lines 23–35, Column (a))

Solely for purposes of section 4980H, an employer may treat an
offer of health coverage to a full-time employee but not his or her
dependents under a non-calendar year plan as an offer of health
coverage to the full-time employee and his or her dependents for
the calendar months in 2016 that fall within the 2015 plan year, if
the employer takes steps during the 2015 plan year to extend
coverage under the plan to dependents not offered coverage
during the 2013 or 2014 plan years (or both) and if the employee
was not offered dependent health coverage during the 2013 or
2014 plan year. An employer using this transition relief for any
month in 2016 is not eligible to report using the Qualifying Offer
Method for 2016. This relief does not apply for purposes of
reporting offers of coverage to dependents on Form 1095-C.

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

Form 1095–C . . . . . . . . . . . . . . .

12 min.

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 Products Coordinating Committee,
SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526,
Washington, DC 20224. Do not send the form to this office.
Instead, see Where To File, earlier.

Interim guidance regarding multiemployer arrangements.
For a description of multiemployer arrangement interim guidance
which relates to the treatment of certain coverage provided
through a multiemployer arrangement, see Offer of health
coverage in the Definitions section.

Instructions for Forms 1094-C and 1095-C (2016)

Form 1094–C . . . . . . . . . . . . . . .

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