i1094-b_and_1095_b--2021-00-00

2021

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 relating to Forms
1094-B, Transmittal of Health Coverage Information Returns,
and 1095-B, Health Coverage, and their instructions, such as
legislation enacted after they were published, go to IRS.gov/
Form1094B and IRS.gov/Form1095B.

What’s New
Extension of due date for furnishing statements. The due
date for furnishing Form 1095-B to individuals is extended from
January 31, 2022, to March 2, 2022. See Proposed Regulations
section 1.6055-1(g) and Extension of time to furnish statement to
recipients, later. A provider of minimum essential coverage will
be treated as timely furnishing Form 1095-B to individuals if the
form is made available through the provider’s website and
certain conditions are met. See Proposed Regulations section
1.6055-1(g) and Alternative manner of furnishing statements,
later.

Additional Information

For information relating 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 relating to reporting by Providers of
Minimum Essential Coverage, go to IRS.gov/Affordable-CareAct/Employers/Information-Reporting-by-Providers-of-MinimumEssential-Coverage.
For information relating to filing Forms 1094-B and 1095-B
electronically, visit IRS.gov/For-Tax-Pros/Software-Developers/
Information-Returns/Affordable-Care-Act-Information-ReturnAir-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. Eligibility for certain types of minimum
essential coverage can affect a taxpayer's eligibility for the
premium tax credit.

plans, individual market plans, and 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.
Minimum essential coverage doesn't include coverage

TIP 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, including individual coverage
HRAs, will generally 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 nonemployees 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
nonemployees. 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.
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 is generally
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 2021 (filing in
2022), health insurance issuers and carriers are encouraged
(but not required) to report coverage in catastrophic health plans
enrolled in through the Marketplace.

Minimum essential coverage includes
government-sponsored programs, eligible employer-sponsored
Dec 09, 2021

Cat. No. 63017B

Eligible Employer-Sponsored Plans

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

Eligible employer-sponsored plans are minimum essential
coverage and include the following.

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.

1. Group health insurance coverage for employees under the
following.

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

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

5. Coverage administered by the Department of Veterans
Affairs that is:

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

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

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

b. CHAMPVA, or

2. A self-insured group health plan for employees. Generally,
an HRA, including an individual coverage HRA, is a
self-insured group health plan.

c. Comprehensive health care for children suffering from
spina bifida who are the children of Vietnam veterans
and veterans of covered service in Korea.

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.

6. Coverage for Peace Corps volunteers.
7. The Nonappropriated Fund Health Benefits Program of the
Department of Defense.

Health insurance issuers or carriers will file Form 1095-B for
all insured employer coverage. Plan sponsors are responsible
for reporting self-insured employer coverage. Plan sponsors that
are employers subject to the employer shared responsibility
provisions must generally 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.

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.

Plan sponsors of self-insured employer coverage include:

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).

• 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.

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 a business owner under a plan that is
eligible employer-sponsored coverage with respect to at
least one employee.

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

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.

Government-Sponsored Programs

The following government-sponsored programs are minimum
essential coverage.

5. The Basic Health Program.

1. Medicare Part A.

6. Coverage of pregnancy-related services that consists of full
Medicaid benefits.

2. Medicaid, except for the following programs.

7. Coverage under a section 1115 demonstration waiver
program.

a. Optional coverage of family planning services.
b. Optional coverage of tuberculosis-related services.

8. Specific programs listed at CMS.gov/CCIIO/Programs-andInitiatives/Health-Insurance-Market-Reforms/MinimumEssential-Coverage.html (click on the link for “approved
plans”).

c. Coverage of pregnancy-related services.
d. Coverage of medical emergency services.
e. Coverage of medically needy individuals.

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.

f. Coverage of COVID-19 testing and diagnostic services.
3. The Children’s Health Insurance Program (CHIP).
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Instructions for Forms 1094-B and 1095-B (2021)

Coverage in More Than One Minimum Essential
Coverage Plan or Program

Extension of Time To File

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.

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 Forms 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 its instructions for more
information about extensions of time to file.

Generally, reporting is also not required for an individual’s
minimum essential coverage for a month if that minimum
essential coverage is offered only to individuals who are also
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.

Where To File

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 can also 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.
Send all information returns filed on paper to the following.

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.

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

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, including an individual coverage HRA, and a
non-HRA group health plan sponsored by another employer
(such as spousal coverage) or an individual is covered by an
individual coverage HRA, 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).

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.

▼

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

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.

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.

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

For forms filed in 2022 reporting coverage provided in
calendar year 2021, Forms 1094-B and 1095-B are required to
be filed by February 28, 2022, or March 31, 2022, if filing
electronically.
See Statements Furnished to Individuals, later, for
information on when Form 1095-B must be furnished.
Instructions for Forms 1094-B and 1095-B (2021)

Use the following address:

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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.

regulations require forms and packages to be sent by first-class
mail. Returns filed with the IRS must be printed in landscape
format.
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.

Void Box

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

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 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.

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.
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.

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 1 tax year at a time. If you need a waiver for more
than 1 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 $280 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
2021 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.

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)

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

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.

Covered Individuals (Part IV)

!

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

CAUTION

Substitute Returns Filed With the IRS

Example 1. Tim enrolls in health insurance with Ace
Insurance Company in January 2021. Tim fails to pay his
premiums for November and December 2021 and January 2022.
Ace sends Tim a Form 1095-B on January 31, 2022, reporting
coverage for every month in 2021. On February 1, 2022, Ace
cancels Tim’s coverage effective November 1, 2021. Ace must

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.
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Instructions for Forms 1094-B and 1095-B (2021)

responsible individuals, stating that responsible individuals
may receive a copy of their statement upon request. The
notice must include an email address, a physical address to
which a request for a statement may be sent, and a
telephone number that responsible individuals may use to
contact the provider with any questions. A notice posted on
a provider’s website must be written in plain, non-technical
terms and with letters of a font size large enough, including
any visual clues or graphical figures, to call to a viewer’s
attention that the information pertains to tax statements
reporting that individuals had health coverage. For example,
a provider’s website provides a clear and conspicuous
notice if it (1) includes a statement on the main page—or a
link on the main page, reading “Tax Information,” to a
secondary page that includes a statement—in capital
letters, “IMPORTANT HEALTH COVERAGE TAX
DOCUMENTS”; (2) explains how responsible individuals
may request a copy of Form 1095-B, Health Coverage, (or,
for an applicable large employer member that sponsors a
self-insured group health plan and makes a return in
accordance with Regulations section 1.6055-1(f)(2)(i),
explains how non-full-time employees and nonemployees
who are enrolled in the plan may request a copy of Form
1095-C, Employer-Provided Health Insurance Offer and
Coverage); and (3) includes the provider’s email address,
mailing address, and telephone number.

send Tim a corrected Form 1095-B reporting that Tim was
covered only for January through October 2021. 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 2021.
Example 2. Sharon is enrolled in Medicaid for January
through September 2021. The Medicaid agency files a Form
1095-B and furnishes a statement to Sharon reporting coverage
for January through September 2021. In April 2022, Sharon is
approved for Medicaid coverage beginning on November 1,
2021. 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 2021.

Statements Furnished to Individuals

Filers of Form 1095-B must furnish a copy by March 2, 2022, to
the person identified as the "responsible individual" on the form
for coverage in 2021. However, a provider of minimum essential
coverage will be treated as timely furnishing Form 1095-B to
individuals if the form is made available through the provider’s
website and certain conditions are met. See Proposed
Regulations section 1.6055-1(g) and Alternative manner of
furnishing statements, later.
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.

• The provider must retain the notice in the same location on
its website through October 17, 2022.

• The provider must furnish the statement to a requesting

responsible individual within 30 days of the date the request
is received. To satisfy this requirement, the provider may
furnish the statement electronically if the recipient
affirmatively consents.

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 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.

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 may also 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.
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.

Extension of time to furnish statement to recipients. The
due date for furnishing Form 1095-B is automatically extended
from January 31, 2022, to March 2, 2022. Thus, no additional
extensions will be granted.

Substitute Statements to Recipients

Alternative manner of furnishing statements. A provider of
minimum essential coverage will be treated as timely furnishing
Form 1095-B to individuals if the provider uses the alternative
manner of furnishing statements described in Proposed
Regulations section 1.6055-1(g). If the provider is an applicable
large employer (as defined under Treasury Regulations section
54.4980H-1(a)(4)) that offers employer-sponsored self-insured
health coverage, the employer may use the alternative manner
of furnishing for statements to non-full-time employees and
nonemployees who are enrolled in the self-insured health
coverage. See Who Must File, earlier. To use the alternative
manner of furnishing statements, the following conditions must
be met.
• The provider must provide clear and conspicuous notice, in
a location on its website that is reasonably accessible to all
Instructions for Forms 1094-B and 1095-B (2021)

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.

Information Reporting Penalties

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

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B. Employer-sponsored coverage, except for an individual
coverage HRA.
C. Government-sponsored program.
D. Individual market insurance.
E. Multiemployer plan.
F. Other designated minimum essential coverage.
G. Employer-sponsored coverage that is an individual coverage
HRA.

statements required to be furnished for 2021 tax year returns,
the following apply.
• The penalty for failure to file a correct information return is
$280 for each return for which the failure occurs, with the
total penalty for a calendar year not to exceed $3,426,000.
• The penalty for failure to provide a correct payee statement
is $280 for each statement for which the failure occurs, with
the total penalty for a calendar year not to exceed
$3,426,000.
• 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 9. For 2021, leave this line blank.

Part II—Information About Certain
Employer-Sponsored Coverage

This part is completed only by issuers or carriers of insured
group health plans, including coverage purchased through the
SHOP.

Waiver of Penalties
The penalties may be waived if the failure was due to reasonable
cause and not willful neglect. See section 6724, Regulations
section 301.6724-1, and Proposed Regulations section
1.6055-1(h). For additional information, see Pub. 1586.

Insurance companies entering code A or B on line 8 will

TIP complete Part II. Employers reporting self-insured group

health plan coverage on Form 1095-B, except for an
individual coverage HRA, 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.

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

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.

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 at
IRS.gov/EIN. 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 for more
information.
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 Form 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.

Part III—Issuer or Other Coverage Provider

Specific Instructions for Form 1095-B

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.

Part I—Responsible Individual

Part IV—Covered Individuals

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

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.

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.

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.

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 1 day per month for all 12 months of the calendar year.

Line 3. Enter the responsible individual’s date of birth
(YYYY/MM/DD) only if line 2 is blank.

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 1 day.
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.

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).
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Instructions for Forms 1094-B and 1095-B (2021)

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

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. 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.

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

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

Instructions for Forms 1094-B and 1095-B (2021)

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

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