Form 1094-B, Transmittal of Health Coverage Information Returns

2017

Department of the Treasury
Internal Revenue Service

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

Future Developments

For the latest information about developments related to
Forms 1094-B, Transmittal of Health Coverage
Information Returns, and 1095-B, Health Coverage, and
the instructions, such as legislation enacted after they
were published, go to IRS.gov/Form1094B and IRS.gov/
Form1095B.

What’s New
Filing requirements. Health insurance issuers and
carriers are encouraged (but not required) to report
coverage in catastrophic health plans enrolled in through
the Marketplace for months in 2017.

Additional Information

For information related to the Affordable Care Act, visit
IRS.gov/ACA.
For the final regulations relating to Form 1095-B
reporting, see T.D. 9660, 2014-13 I.R.B. at IRS.gov/IRB/
2014-13_IRB/AR08.html.
For additional guidance and proposed regulatory
changes relating to Form 1095-B reporting, 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.
For additional information related to reporting by
Providers of Minimum Essential Coverage, go to IRS.gov/
Affordable-Care-Act/Employers/Information-Reporting-byProviders-of-Minimum-Essential-Coverage.
For information related to filing Forms 1094-B and
1095-B electronically, visit IRS.gov/For-Tax-Pros/
Software-Developers/Information-Returns/AffordableCare-Act-Information-Return-Air-Program.

General Instructions for Forms
1094-B and 1095-B
Purpose of Form

Form 1095-B is used to report certain information to the
IRS and to taxpayers about individuals who are covered
by minimum essential coverage and therefore aren't liable
for the individual shared responsibility payment.
Minimum essential coverage includes
government-sponsored programs, eligible
employer-sponsored plans, individual market plans, and
Sep 11, 2017

other coverage the Department of Health and Human
Services designates as minimum essential coverage.
Minimum essential coverage is described in more detail
under Who Must File, later. Additional information about
minimum essential coverage and the individual shared
responsibility provision is at IRS.gov/Affordable-Care-Act/
Individuals-And-Families/Individual-SharedResponsibility-Provision.
Minimum essential coverage doesn't include

TIP coverage consisting solely of excepted benefits.

Excepted benefits include vision and dental
coverage not part of a comprehensive health insurance
plan, workers’ compensation coverage, and coverage
limited to a specified disease or illness.

Who Must File

Every person that provides minimum essential coverage
to an individual during a calendar year must file an
information return reporting the coverage. Filers will use
Form 1094-B (transmittal) to submit Forms 1095-B
(returns).
Employers (including government employers) subject
to the employer shared responsibility provisions
sponsoring self-insured group health plans generally will
report information about the coverage in Part III of Form
1095-C instead of on Form 1095-B. However, employers
that offer employer-sponsored self-insured health
coverage to non-employees who enroll in the coverage
may use Form 1095-B, rather than Form 1095-C, Part III,
to report coverage for those individuals and other family
members. In general, employers with 50 or more full-time
employees (including full-time equivalent employees)
during the prior calendar year are subject to the employer
shared responsibility provisions. See the Instructions for
Forms 1094-C and 1095-C for more information about
who must file Forms 1094-C and 1095-C and for more
information about reporting coverage for non-employees.
Small employers that aren't subject to the employer
shared responsibility provisions sponsoring self-insured
group health plans will use Forms 1094-B and 1095-B to
report information about covered individuals.
Insured coverage. Health insurance issuers and carriers
must file Form 1095-B for most health insurance
coverage, including individual market coverage and
insured coverage sponsored by employers. However,
health insurance issuers and carriers don't report
coverage under the Children’s Health Insurance Program
(CHIP), Medicaid, Medicare (including Medicare
Advantage), or the Basic Health Program provided
through health insurance companies. These types of
coverage are reported by the government sponsors of
those programs.

Cat. No. 63017B

employees only if that government employer isn't subject
to the employer shared responsibility provisions, which
would require reporting on Form 1095-C. The Instructions
for Forms 1094-C and 1095-C contain further information
on reporting options for government entities.

In addition, health insurance issuers and carriers aren't
required to file Form 1095-B to report coverage in
individual market qualified health plans that individuals
enroll in through Health Insurance Marketplaces. This
coverage generally is reported by Marketplaces on Form
1095-A. However, health insurance issuers are required
to file Form 1095-B to report on coverage for employees
obtained through the Small Business Health Options
Program (SHOP). For coverage in 2017 (filing in 2018),
health insurance issuers and carriers are encouraged (but
not required) to report coverage in catastrophic health
plans enrolled in through the Marketplace.

Government-Sponsored Programs

The following government-sponsored programs are
minimum essential coverage.
1. Medicare Part A.
2. Medicaid, except for the following programs:
a. Optional coverage of family planning services.

Eligible Employer-Sponsored Plans

Eligible employer-sponsored plans are minimum essential
coverage and include:

b. Optional coverage of tuberculosis-related
services.

1. Group health insurance coverage for employees
under:

c. Coverage of pregnancy-related services.
d. Coverage of medical emergency services.

a. A governmental plan, such as the Federal
Employees Health Benefits program.

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

b. An insured plan or coverage offered in the small or
large group market within a state.

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

c. A grandfathered health plan offered in a group
market.

4. The TRICARE program, except for the following
options:

2. A self-insured group health plan for employees.

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

As noted earlier, minimum essential coverage doesn't
include coverage consisting solely of excepted benefits.
Excepted benefits include vision and dental coverage not
part of a comprehensive health insurance plan, workers’
compensation coverage, and coverage limited to a
specified disease or illness.

b. Coverage for a line of duty-related injury, illness,
or disease for individuals who have left active
duty.

Health insurance issuers or carriers will file Form
1095-B for all insured employer coverage. Plan sponsors
are responsible for reporting self-insured employer
coverage. Plan sponsors that are employers subject to the
employer shared responsibility provisions generally must
report the coverage on Form 1095-C and other plan
sponsors (such as employers not subject to the employer
shared responsibility provisions and sponsors of
multiemployer plans) report the coverage on Form
1095-B.

5. Coverage administered by the Department of
Veterans Affairs that is:
a. Coverage consisting of the medical benefits
package for eligible veterans.
b. CHAMPVA.
c. Comprehensive health care for children suffering
from spina bifida who are the children of Vietnam
veterans and veterans of covered service in
Korea.

Plan sponsors of self-insured employer coverage
include:
Each participating employer (for its own covered
individuals) in a plan or arrangement established or
maintained by more than one employer;
The association, committee, joint board of trustees, or
similar group of representatives who establish or
maintain a multiemployer plan;
The employee organization for a plan or arrangement
maintained solely by an employee organization; and
Each participating employer (for its own employees)
for a plan or arrangement maintained by a Multiple
Employer Welfare Arrangement.

6. Coverage for Peace Corps volunteers.
7. The Nonappropriated Fund Health Benefits Program
of the Department of Defense.
In general, the government agency sponsoring the
program will file Form 1095-B. The state agency that
administers a Medicaid or CHIP program will file Form
1095-B for coverage under those programs. However,
Medicaid and CHIP agencies in U.S. possessions or
territories (American Samoa, the Commonwealth of the
Northern Mariana Islands, Guam, Puerto Rico, and the
U.S. Virgin Islands) aren’t required to report Medicaid or
CHIP coverage on Form 1095-B.

A government employer may designate another
government entity to report coverage of its employees.
Generally, a designated government entity will file Form
1095-B on behalf of a government employer that sponsors
or maintains a self-insured group health plan for its

When coverage under the Nonappropriated Fund
Health Benefits Program of the Department of Defense or
TRICARE is reported on Form 1095-B, Part I, line 8, filers
should use code C (government-sponsored program).
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Instructions for Forms 1094-B and 1095-B (2017)

This second rule applies to eligible-employer
sponsored coverage only if both types of coverage (the
supplemental coverage and the eligible-employer
sponsored coverage for which section 6055 reporting is
required) are offered by the same employer. For example,
if an employer offers both an insured group health plan
and an HRA that an employee is eligible for if the
employee enrolls in the insured group health plan, and an
employee enrolls in both, the employer is not required to
report the employee’s coverage under the HRA for the
months in which the employee is enrolled in both plans. If,
however, an individual is covered by an HRA sponsored
by one employer and a non-HRA group health plan
sponsored by another employer (such as spousal
coverage), each employer (or the health insurance issuer
or carrier, if the plan is insured) must report the coverage
the employer (or issuer or carrier) provides.
For more information on the reporting of supplemental
coverage, including the rule on when different entities are
treated as a single employer for purposes of the second
rule, see Proposed Regulations section 1.6055-1(d)(2)
and (3).

Coverage designated as minimum essential coverage. The Department of Health and Human Services has
designated the following health benefit plans or
arrangements as minimum essential coverage.
1. Medicare Part C (Medicare Advantage).
2. Refugee Medical Assistance.
3. Coverage provided to business owners who aren't
employees.
4. Coverage under a group health plan provided through
insurance regulated by a foreign government if:
a. A covered individual is physically absent from the
United States for at least 1 day during the month;
or
b. A covered individual is physically present in the
United States for a full month and the coverage
provides health benefits within the United States
while the individual is outside the United States.
5. The Basic Health Program.
6. Coverage of pregnancy-related services that consists
of full Medicaid benefits.

When To File

Generally, the return and transmittal form must be filed
with the IRS on or before February 28 if filing on paper
(March 31 if filing electronically) of the year following the
calendar year of coverage.
You will meet the requirement to file if the form is
properly addressed and mailed on or before the due date.
If the regular due date falls on a Saturday, Sunday, or
legal holiday, file by the next business day. A business
day is any day that isn't a Saturday, Sunday, or legal
holiday.
For forms filed in 2018 reporting coverage provided in
calendar year 2017, Forms 1094-B and 1095-B are
required to be filed by February 28, 2018, or April 2, 2018,
if filing electronically.
See Statements Furnished to Individuals for
information on when Form 1095-B must be furnished.

7. Specific programs listed at CMS.gov/CCIIO/
Programs-and-Initiatives/Health-Insurance-MarketReforms/Minimum-Essential-Coverage.html (click on
the link for “approved plans.”)
Providers of these and later designated programs will
file Form 1095-B. The sponsor for the Basic Health
Program is the state government agency administering
the program.

Coverage in More Than One Minimum Essential
Coverage Plan or Program

If, for any month, an individual is covered by more than
one minimum essential coverage plan or program that is
provided by the same provider, the provider is required to
report only one of the plans or programs for that month.
For example, if an individual is covered by a self-insured
major medical plan and a health reimbursement
arrangement (HRA) provided by the same employer for a
month, the employer is the provider of both types of
coverage and therefore is required to report the coverage
of the individual under only one of the arrangements for
that month.

Extension of Time To File

You can get an automatic 30-day extension of time to file
by completing Form 8809 and filing it with the IRS on or
before the due date for the Form 1094-B and 1095-B.
Form 8809 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 by 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 Form 8809 and the instructions for
more information about extensions of time to file.

Generally, reporting also is not required for an
individual’s minimum essential coverage for a month if
that minimum essential coverage is offered only to
individuals who also are covered by other minimum
essential coverage for which reporting is required. For
example, an insurance company offering a Medicare or
TRICARE supplement for which only individuals enrolled
in Medicare or TRICARE are eligible is not required to
report coverage under the Medicare or TRICARE
supplement.

How to apply. File Form 8809 as soon as you know that
a 30-day extension of time to file is needed. Follow the
instructions on Form 8809, which provide information on
where to fax or mail your Form 8809. You also 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 for more information on filing
online or electronically. See the instructions for Form 8809
for more information.

Under this rule, a state Medicaid agency is not required
to report Medicaid coverage for which only individuals
enrolled in other minimum essential coverage, such as
employer-sponsored coverage or a qualified health plan,
are eligible.
Instructions for Forms 1094-B and 1095-B (2017)

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Where To File

because they fall under the 250 threshold even if you
originally filed 250 or more Forms 1095-B and properly
filed those forms electronically. If you have 300 Forms
1095-B to correct, they must be filed electronically. The
electronic filing requirement doesn't apply if you apply for
and receive a hardship waiver. The IRS encourages you
to file electronically even if you're filing fewer than 250
returns.

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:
▼

Use the following address:
▼

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

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

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

Department of the Treasury
Internal Revenue Service
Center
P.O. Box 219256
Kansas City, MO 64121-9256

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 return but no later than the due date of
the return. The IRS doesn’t process waiver requests until
January 1 of the calendar year the returns are due. You
can't 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. An
approved waiver for original returns will cover corrections
only for the same type of return. If you receive an
approved waiver, don't 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 don't have an approved waiver, you may be
subject to a penalty of up to $260 per return 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, specifies the
communication procedures, transmission formats,
business rules, and validation procedures, and explains
when a return will be accepted, accepted with errors or
rejected for returns filed electronically for calendar year
2017 through the ACA Information Return (AIR) system.
To develop software for use with the AIR system, software
developers, transmitters, and issuers, including
employers filing their own Forms 1094-B and 1095-B,
should use the guidelines provided in Pub. 5165 along
with the Extensible Markup Language (XML) Schemas
published on IRS.gov.

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.

How To File
Filing Paper Returns With the IRS
Shipping and mailing. If you're filing on paper, send the
forms to the IRS in a flat mailing (not folded) and don’t
staple or paperclip the forms together. If you're sending
many forms, you may send them in conveniently sized
packages. On each package, write your name, and
number the packages consecutively. Place Form 1094-B
in package number one and a copy of Form 1094-B in
each additional package. Postal regulations require forms
and packages to be sent by first-class mail. Returns filed
with the IRS must be printed in landscape format.

Reminder. The formatting directions in these instructions
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.

Keeping copies. Generally, keep copies of information
returns you filed with the IRS or maintain the ability to
reconstruct the data for at least 3 years, from the due date
of the returns.

Substitute Returns Filed With the IRS

If you're 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 aren't required to file Forms 1095-C electronically.
As another example, if you have 150 Forms 1095-B to
correct, you may file the corrected returns on paper

See Pub. 5223, General Rules and Specifications for
Affordable Care Act Substitute Forms 1095-A, 1094-B,
1095-B, 1094-C, and 1095-C, 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-B and 1095-B (2017)

Void Box

1095-B reporting that Tim was covered only for January
through October 2017. If Ace filed the Form 1095-B with
the IRS, it must file a corrected Form 1095-B with the IRS
reporting coverage only for January through October
2017.

Don't use this box on Form 1095-B.

Corrected Form 1095-B

For information about filing corrections for electronically
filed forms, see section 7.1 of Pub. 5165. A corrected
return should be filed as soon as possible after an error is
discovered. File corrected returns as follows.
Form 1095-B: Fully complete Form 1095-B and enter
an “X” in the CORRECTED checkbox. File a Form
1094-B Transmittal with the corrected Forms 1095-B.
(Do not file a corrected Form 1094-B.)
Recipient's statement: A copy of the corrected Form
1095-B must be furnished to the individual who
received the original Form 1095-B.

Example 2. Sharon is enrolled in Medicaid for January
through September 2017. The Medicaid agency files a
Form 1095-B and furnishes a statement to Sharon
reporting coverage for January through September 2017.
In April 2018, Sharon is approved for Medicaid coverage
beginning on November 1, 2017. The Medicaid agency
must file a corrected Form 1095-B with the IRS and
furnish Sharon a corrected statement reporting coverage
for January through September and November through
December 2017.

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

Statements Furnished to Individuals

Filers of Form 1095-B must furnish a copy by January 31,
2018, to the person identified as the “responsible
individual” on the form for coverage in 2017.
The “responsible individual” is the person who, based
on a relationship to the covered individuals, the primary
name on the coverage, or some other circumstances,
should receive the statement. Generally, the statement
recipient should be the taxpayer (tax filer) who would be
liable for the individual shared responsibility payment for
the covered individuals, if that person is known. A
statement recipient may be a parent if only minor children
are covered individuals, a primary subscriber for insured
coverage, an employee or former employee in the case of
employer-sponsored coverage, a uniformed services
sponsor for TRICARE, or another individual who should
receive the statement. Filers may, but aren't required to,
furnish a statement to more than one recipient.

See the next chart for examples of errors and

TIP step-by-step instructions for filing corrected
returns.

Original Form 1095-B Filed With the IRS and Furnished to the
Recipient
IF any of the following are
incorrect ...

THEN ...

Name of responsible individual
(Part I)

1. Fully complete a new Form
1095-B and enter an “X” in the
CORRECTED checkbox
2. File a Form 1094-B Transmittal
with the corrected Form 1095-B
3. Furnish a copy of the corrected
Form 1095-B to the person
identified as the responsible
individual

Origin of the Health Coverage
(Part I)

Copies of Form 1095-B furnished to recipients may
include a truncated SSN or other TIN, if applicable, of the
statement recipient and covered individuals by showing
only the last four digits of the SSN or other TIN and
replacing the first five digits with asterisks (*) or Xs.
Copies of Form 1095-B furnished to recipients also may
truncate the EIN of an employer reported in Part II, if any.
The filer’s EIN may not be truncated on the statement
furnished to recipients. Truncation of TINs, including EINs,
is not allowed on returns filed with the IRS.

Social security number (SSN) or
taxpayer identification number
(TIN) (Part I)
Information About Certain
Employer-Sponsored Coverage
(Part II)

In general, 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 recipient’s last
known permanent address, or, if no permanent address is
known, to the recipient’s temporary address.

Issuer or Other Coverage
Provider (Part III)
Covered Individuals (Part IV)

!

Consent to furnish statement electronically. Except
as provided below, a filer is required to obtain affirmative
consent to furnish a statement electronically. The
requirement to obtain affirmative consent to furnish a
statement electronically ensures that statements are sent
electronically only to individuals who are able to access
them. The consent must relate specifically to receiving
Form 1095-B electronically. A recipient may consent on
paper or electronically, such as by email. If consent is on
paper, the recipient must confirm the consent
electronically. A statement may be furnished electronically

You must file a corrected return to report
retroactive changes in coverage.

CAUTION

Example 1. Tim enrolls in health insurance with Ace
Insurance Company in January 2017. Tim fails to pay his
premiums for November and December 2017 and
January 2018. Ace sends Tim a Form 1095-B on January
31, 2018, reporting coverage for every month in 2017. On
February 1, 2018, Ace cancels Tim’s coverage effective
November 1, 2017. Ace must send Tim a corrected Form
Instructions for Forms 1094-B and 1095-B (2017)

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by email or by informing the recipient how to access the
statement on the filer’s website. Statements reporting
coverage under an expatriate health plan, however, may
be furnished electronically unless the recipient has
explicitly refused to consent to receive the statement in an
electronic format.

Specific Instructions for Form 1094-B
Line 1. Enter the filer’s complete name.
Line 2. Enter the filer’s nine-digit employer identification
number (EIN). If you don't have an EIN, you may apply for
one online. Go to IRS.gov and enter “EIN” in the search
box. You also may 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 for
more information.

Extension of Time To Furnish Statement to
Recipients

You may request an extension of time to furnish
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 the
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 this
purpose, the term filer means the Designated Government
Entity, if applicable.

Lines 3 and 4. Enter the name and telephone number,
including area code, 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-B or 1095-B.
Lines 5–8. Enter the filer’s complete address where all
correspondence will be sent. If mail is delivered to a P.O.
box and not a street address, enter the box number
instead of the street address.
Line 9. Enter the total number of Forms 1095-B that are
transmitted with Form 1094-B.

Specific Instructions for Form 1095-B

Substitute Statements to Recipients

If you aren't using the official IRS form to furnish
statements to recipients, see Pub. 5223, 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.

Part I—Responsible Individual
Line 1. Enter the name of the responsible individual
(statement recipient). See the description of who is a
“responsible individual” in Statements Furnished to
Individuals, earlier.

Information Reporting Penalties

Line 2. Enter the nine-digit social security number (SSN)
of the responsible individual (111-11-1111). If the
responsible individual doesn't have an SSN, enter the
responsible individual’s other TIN. No SSN or other TIN is
required if the responsible individual isn't a covered
individual identified in Part IV. See Statements Furnished
to Individuals, earlier, for information on truncating the
SSN or other TIN.

A provider of minimum essential coverage that fails to
comply with the information reporting requirements may
be subject to the general information 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 2017 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 $3,218,500.
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 $3,218,500.
Special rules apply that increase the per-return and
per-statement and total penalties with no maximum
limitations if there is intentional disregard of the
requirement to file the returns and furnish recipient
statements.

Line 3. Enter the responsible individual’s date of birth
(YYYY/MM/DD) only if line 2 is blank.
Lines 4–7. Enter the complete mailing address of the
responsible individual. If mail isn't delivered to the street
address and the responsible individual has a P.O. box,
enter the box number instead of the street address.
Line 8. Enter the letter identifying the Origin of the Health
Coverage. See Who Must File, earlier, to determine which
types of coverage fall under each category listed below.
A. Small Business Health Options Program (SHOP).
B. Employer-sponsored coverage.
C. Government-sponsored program.
D. Individual market insurance.
E. Multiemployer plan.
F. Other designated minimum essential coverage.

Waiver of Penalties
The 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). For additional
information, see Pub. 1586.

Line 9. For 2017, leave this line blank.

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Instructions for Forms 1094-B and 1095-B (2017)

Part II—Information About Certain
Employer-Sponsored Coverage

If there are more than six covered individuals, complete
this information for the additional covered individuals on
Part IV, Continuation Sheet(s). Do not count the
continuation sheet(s) as additional Forms 1095-B in the
count of forms submitted with the accompanying Form
1094-B.

This part is completed only by issuers or carriers of
insured group health plans, including coverage purchased
through the SHOP.
Insurance companies entering codes A or B on

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 section 6055 and its regulations. We request it to
confirm that insured individuals are covered by minimum
essential coverage and therefore aren't liable for the
individual shared responsibility payment. If you don't
provide this information, we may be unable to determine
whether covered individuals are liable for the individual
shared responsibility payment; providing false or
fraudulent information may subject you to penalties. We
may disclose this information to the Department of Justice
for civil or criminal investigation, and to cities, states, and
the District of Columbia for use in administering their tax
laws. We may also disclose this information to other
countries under a tax treaty, to Federal and state agencies
to enforce Federal nontax criminal laws, or to Federal law
enforcement and intelligence agencies to combat
terrorism.

TIP line 8 will complete Part II. Employers reporting

self-insured group health plan coverage on Form
1095-B enter code B on line 8, but don't complete Part II.
If you entered code B for self-insured coverage, skip Part
II and go to Part III.
Lines 10–15. Enter the name, EIN, and complete mailing
address for the employer sponsoring the coverage. If mail
isn't delivered to the street address and the employer has
a P.O. box, enter the box number instead of the street
address. See Statements Furnished to Individuals, earlier,
for information on truncating the employer's EIN. If the
employer is a member of a controlled group, enter
information for the specific controlled group member that
is the covered employee’s employer. If the coverage is
provided through an association or a Multiple Employer
Welfare Arrangement, enter information for the
participating employer of the covered employee. Don't
complete Part II if the coverage is provided through a
multiemployer plan.

Part III—Issuer or Other Coverage Provider

You aren't 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.

Lines 16–22. Enter your name, EIN, and complete
mailing address. The provider of the coverage is the
issuer or carrier of insured coverage, sponsor of a
self-insured employer plan, government agency providing
government-sponsored coverage, or other coverage
sponsor. Enter on line 18 the telephone number that an
individual seeking additional information may call to speak
to a person.

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

Part IV—Covered Individuals
Column (a). Enter the name of each covered individual.
Column (b). Enter the nine-digit SSN or other TIN for
each covered individual (111-11-1111). The field may be
left blank if the covered individual doesn’t have a TIN. See
Statements Furnished to Individuals, earlier, for
information on truncating the SSN or other TIN.

10 min.

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

1 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
send us comments from IRS.gov/FormComments. Or you
can write to the Internal Revenue Service, Tax Forms and
Publications Division, 1111 Constitution Ave. NW,
IR-6526, Washington, DC 20224. Don't send the form to
this office.

Column (c). Enter a date of birth (YYYY/MM/DD) for the
covered individual only if an SSN or other TIN isn't
entered in column (b).
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 wasn't covered for all 12
months, check the applicable box(es) for the months in
which the individual was covered for at least one day.

Instructions for Forms 1094-B and 1095-B (2017)

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

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