1095-B Health Coverage

Form

1095-B

Department of the Treasury
Internal Revenue Service

Part I
1

DRAFT AS OF
July 27, 2017
DO NOT FILE
Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095B for instructions and the latest information.

5

City or town

12 Street address (including room or suite no.)

16

.

.

.

3 Date of birth (if SSN or other TIN is not available)

6

State or province

7

9

Reserved

Country and ZIP or foreign postal code

▶

13

City or town

11

Employer identification number (EIN)

14

State or province

15

Country and ZIP or foreign postal code

17

Employer identification number (EIN)

18

Contact telephone number

21

State or province

22

Country and ZIP or foreign postal code

Issuer or Other Coverage Provider (see instructions)

Name

19 Street address (including room or suite no.)

Part IV

2 Social security number (SSN) or other TIN

Information About Certain Employer-Sponsored Coverage (see instructions)

Employer name

Part III

2017

CORRECTED

▶

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

Part II

OMB No. 1545-2252

Responsible Individual

Name of responsible individual

4 Street address (including apartment no.)

10

VOID

Health Coverage

▶

560116

20

City or town

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

(b) SSN or other TIN

(c) DOB (if SSN or other (d) Covered
TIN is not available) all 12 months

(e) Months of coverage

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

23

24

25

26

27

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

Cat. No. 60704B

Form 1095-B (2017)

Form 1095-B (2017)

DRAFT AS OF
July 27, 2017
DO NOT FILE

Instructions for Recipient

This Form 1095-B provides information needed to report on your income tax
return that you, your spouse (if you file a joint return), and individuals you
claim as dependents had qualifying health coverage (referred to as “minimum
essential coverage”) for some or all months during the year. Individuals who
don't have minimum essential coverage and don't qualify for an exemption
from this requirement may be liable for the individual shared responsibility
payment.
Minimum essential coverage includes government-sponsored programs,
eligible employer-sponsored plans, individual market plans, and other
coverage the Department of Health and Human Services designates as
minimum essential coverage. For more information on the requirement to
have minimum essential coverage and what is minimum essential coverage,
see www.irs.gov/Affordable-Care-Act/Individuals-and-Families/IndividualShared-Responsibility-Provision.
Providers of minimum essential coverage are required to furnish
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to other individuals covered under the policy if they
request it for their records.

TIP

Additional information. For additional information about the tax provisions
of the Affordable Care Act (ACA), including the individual shared
responsibility provisions, the premium tax credit, and the employer shared
responsibility provisions, see www.irs.gov/Affordable-Care-Act/Individualsand-Families or call the IRS Healthcare Hotline for ACA questions
(1-800-919-0452).
Part I. Responsible Individual, lines 1–9. Part I reports information about
you and the coverage.
Lines 2 and 3. Line 2 reports your social security number (SSN) or other
taxpayer identification number (TIN), if applicable. For your protection, this
form may show only the last four digits. However, the coverage provider is
required to report your complete SSN or other TIN, if applicable, to the IRS.
Your date of birth will be entered on line 3 only if line 2 is blank.

!
▲

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

560216
Page 2

Line 8. This is the code for the type of coverage in which you or other
covered individuals were enrolled. Only one letter will be entered on this line.
A. Small Business Health Options Program (SHOP)
B. Employer-sponsored coverage
C. Government-sponsored program
D. Individual market insurance
E . Multiemployer plan
F . Other designated minimum essential coverage

If you or another family member received health insurance
coverage through a Health Insurance Marketplace (also known as
an Exchange), that coverage will generally be reported on a
Form 1095-A rather than a Form 1095-B. If you or another family member
received employer-sponsored coverage, that coverage may be reported on a
Form 1095-C (Part III) rather than a Form 1095-B. For more information, see
www.irs.gov/Affordable-Care-Act/Questions-and-Answers-About-HealthCare-Information-Forms-for-Individuals.

TIP

Line 9. Reserved.
Part II. Information About Certain Employer-Sponsored Coverage, lines
10–15. If you had employer-sponsored health coverage, this part may
provide information about the employer sponsoring the coverage. This part
may show only the last four digits of the employer's EIN. This part also may
be left blank, even if you had employer-sponsored health coverage. If this
part is blank, you do not need to fill in the information or return it to your
employer or other coverage provider.
Part III. Issuer or Other Coverage Provider, lines 16–22. This part reports
information about the coverage provider (insurance company, employer
providing self-insured coverage, government agency sponsoring coverage
under a government program such as Medicaid or Medicare, or other
coverage sponsor). Line 18 reports a telephone number for the coverage
provider that you can call if you have questions about the information
reported on the form.
Part IV. Covered Individuals, lines 23–28. This part reports the name, SSN
or other TIN, and coverage information for each covered individual. A date of
birth will be entered in column (c) only if the SSN or other TIN isn't entered in
column (b). Column (d) will be checked if the individual was covered for at
least one day in every month of the year. For individuals who were covered
for some but not all months, information will be entered in column (e)
indicating the months for which these individuals were covered. If there are
more than six covered individuals, see Part IV, Continuation Sheet(s), for
information about the additional covered individuals.

Form 1095-B (2017)
Name of responsible individual

Part IV

DRAFT AS OF
July 27, 2017
DO NOT FILE
Social security number (SSN) or other TIN

(b) SSN or other TIN

(c) DOB (if SSN or other (d) Covered
TIN is not available) all 12 months

(e) Months of coverage

Jan

30

Page 3

Date of birth (if SSN or other TIN is not available)

Covered Individuals — Continuation Sheet
(a) Name of covered individual(s)

29

560317

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

31

32

33

34

35

36

37

38

39

40

Form 1095-B (2017)