1095-B Health Coverage

560118

Form

1095-B

Department of the Treasury
Internal Revenue Service

Part I
1

Do not attach to your tax return. Keep for your records.
Go to www.irs.gov/Form1095B for instructions and the latest information.

Part II

5

City or town

.

.

.

2 Social security number (SSN) or other TIN

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

6

State or province

7

Country and ZIP or foreign postal code

9

Reserved

11

Employer identification number (EIN)

▶

Information About Certain Employer-Sponsored Coverage (see instructions)

Employer name

12 Street address (including room or suite no.)

Part III

13

City or town

14

State or province

15

Country and ZIP or foreign postal code

17

Employer identification number (EIN)

18

Contact telephone number

21

State or province

22

Country and ZIP or foreign postal code

Issuer or Other Coverage Provider (see instructions)

Name

19 Street address (including room or suite no.)

Part IV

2021

Responsible Individual

Name of responsible individual–First name, middle name, last name

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

16

OMB No. 1545-2252

CORRECTED

▶

▶

4 Street address (including apartment no.)

10

VOID

Health Coverage

20

City or town

Covered Individuals (Enter the information for each covered individual.)
(a) Name of covered individual(s)
First name, middle initial, last name

(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 (2021)

560220
Page 2

Form 1095-B (2021)

Instructions for Recipient
This Form 1095-B provides information about the individuals in your tax
family (yourself, spouse, and dependents) who had certain health coverage
(referred to as “minimum essential coverage”) for some or all months during
the year. 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.
Before 2019, individuals who did not have minimum essential coverage
and did not qualify for an exemption from this requirement could be liable for
the individual shared responsibility payment. Beginning in 2019, individuals
will not be responsible for the individual shared responsibility payment
because the payment amount is reduced to $0. However, if individuals in
your tax family are eligible for certain types of minimum essential coverage,
you may not be eligible for the premium tax credit. For more information on
the premium tax credit, see Pub. 974, Premium Tax Credit (PTC).
Providers of minimum essential coverage are required to furnish
only one Form 1095-B for all individuals whose coverage is
reported on that form. As the recipient of this Form 1095-B, you
should provide a copy to 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, and the premium tax credit, see www.irs.gov/ACA
or call the IRS Healthcare Hotline for ACA questions (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.
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
G . Individual coverage health reimbursement arrangement (HRA)

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 may also
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 is not entered
in column (b). Column (d) will be checked if the individual was covered for at
least 1 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.

560318
Page 3

Form 1095-B (2021)
Social security number (SSN) or other TIN

Name of responsible individual–First name, middle name, last name

Part IV

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

Covered Individuals — Continuation Sheet
(a) Name of covered individual(s)
First name, middle initial, last name

(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

29

30

31

32

33

34

35

36

37

38

39

40

Form 1095-B (2021)