Printable IRS 1095-A Template

The IRS 1095-A form is a tax document that provides information about health insurance coverage obtained through the Health Insurance Marketplace. This form is essential for taxpayers who need to report their health coverage status when filing their federal tax returns. Understanding how to accurately fill out this form is crucial for ensuring compliance and maximizing potential tax benefits.

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The IRS 1095-A form plays a crucial role in the health insurance landscape, particularly for those who have purchased coverage through the Health Insurance Marketplace. This form provides essential information about your health insurance plan, including the months you were covered, the premiums you paid, and any premium tax credits you may have received. Understanding this form is vital, as it helps you accurately report your health coverage when filing your federal tax return. If you received financial assistance to help pay for your insurance, the 1095-A also outlines the amount of that assistance, which can significantly impact your tax obligations. Additionally, the form includes details about the specific insurance provider and the plan’s coverage, making it a key document for ensuring compliance with the Affordable Care Act. As tax season approaches, having a clear grasp of the 1095-A form can streamline the filing process and help you avoid potential pitfalls related to your health insurance reporting.

Common mistakes

Not including all household members. It's important to list everyone who was part of your household during the coverage year.
Incorrect Social Security numbers. Ensure that each person's Social Security number is accurate to avoid processing delays.
Missing months of coverage. Be sure to indicate every month that you had health coverage to reflect your situation accurately.
Failing to report premium tax credits. If you received premium tax credits, these must be reported correctly on the form.
Using the wrong plan start and end dates. Verify the dates of your coverage to ensure they match the records from your insurance provider.
Not double-checking for typos. Small mistakes in names or numbers can lead to significant issues. Always review your form carefully.
Ignoring instructions. The IRS provides guidance for filling out the form. Follow these instructions closely to avoid errors.
Submitting without a copy. Keep a copy of the completed form for your records. This is essential for future reference.
Missing the filing deadline. Ensure you submit the form on time to avoid penalties and complications with your tax return.

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Key takeaways

The IRS 1095-A form is essential for individuals who have health insurance through the Health Insurance Marketplace. Here are key takeaways to consider when filling out and using this form:

Purpose of the Form: The 1095-A form provides information about your health coverage and is used to determine your eligibility for premium tax credits.
Who Receives It: You will receive a 1095-A if you or someone in your household enrolled in a Marketplace plan during the tax year.
Filing Deadline: The form is typically sent out by January 31st of the following year, so keep an eye out for it in your mail or online account.
Important Information Included: The form includes details such as the months you were covered, the premium amounts, and the second lowest cost silver plan (SLCSP) premium.
Using the Form: You will need the information on the 1095-A to complete your federal tax return accurately.
Correcting Errors: If you find mistakes on your 1095-A, contact the Marketplace to request a corrected form.
Impact on Tax Credits: The information on the form directly affects the amount of premium tax credit you may claim, so accuracy is crucial.
Record Keeping: Keep a copy of your 1095-A with your tax records for at least three years after filing.
Additional Resources: The IRS provides instructions and guidance on how to read and use the 1095-A, which can be helpful if you have questions.

IRS 1095-A Example

CAUTION: NOT FOR FILING

Form 1095-A is provided here for informational purposes only.

Health Insurance Marketplaces use Form 1095-A to report information on enrollments in a qualified health plan in the individual market through the Marketplace. As the form is to be completed by the Marketplaces, individuals cannot complete and use Form 1095-A available on IRS.gov. Individuals receiving a completed Form 1095-A from the Health Insurance Marketplace will use the information received on the form and the guidance in the instructions to assist them in filing an accurate tax return.

Form 1095-A

Department of the Treasury Internal Revenue Service

Health Insurance Marketplace Statement

▶ Do not attach to your tax return. Keep for your records.

▶Go to www.irs.gov/Form1095A for instructions and the latest information.

VOID

CORRECTED

OMB No. 1545-2232

2021

		Recipient Information
Part I		Recipient Information

1	Marketplace identifier		2	Marketplace-assigned policy number	3	Policy issuer’s name

4	Recipient’s name				5	Recipient’s SSN	6	Recipient’s date of birth

7	Recipient’s spouse’s name				8	Recipient’s spouse’s SSN	9	Recipient’s spouse’s date of birth

10	Policy start date		11	Policy termination date	12	Street address (including apartment no.)

13	City or town		14	State or province	15	Country and ZIP or foreign postal code

Covered Individuals

Part II

A. Covered individual name

B. Covered individual SSN

C. Covered individual

D. Coverage start date

E. Coverage termination date

date of birth

Coverage Information

Part III

Month

A. Monthly enrollment premiums

B. Monthly second lowest cost silver

C. Monthly advance payment of

plan (SLCSP) premium

premium tax credit

January

February

March

April

May

June

July

August

September

October

November

December

Annual Totals

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

Cat. No. 60703Q

Form 1095-A (2021)

Page 2

Instructions for Recipient

You received this Form 1095-A because you or a family member enrolled in health insurance coverage through the Health Insurance Marketplace. This Form 1095-A provides information you need to complete Form 8962, Premium Tax Credit (PTC). You must complete

Form 8962 and file it with your tax return (Form 1040, Form

1040-SR, or Form 1040-NR) if any amount other than zero is shown in Part III, column C, of this Form 1095-A (meaning that you received premium assistance through advance payments of the premium tax credit (also called advance credit payments)) or if you want to take the premium tax credit. The filing requirement applies whether or not you’re otherwise required to file a tax return. If you are filing Form 8962, you cannot file Form 1040-NR-EZ, Form

1040-SS, or Form 1040-PR. The Marketplace has also reported the information on this form to the IRS. If you or your family members enrolled at the Marketplace in more than one qualified health plan policy, you will receive a Form 1095-A for each policy. Check the information on this form carefully. Please contact your Marketplace if you have questions concerning its accuracy. If you or your family members were enrolled in a Marketplace catastrophic health plan or separate dental policy, you aren’t entitled to take a premium tax credit for this coverage when you file your return, even if you received a Form 1095-A for this coverage. For additional information related to Form 1095-A, go to www.irs.gov/Affordable-Care-Act/Individuals-and- Families/Health-Insurance-Marketplace-Statements.

Additional information. For additional information about the tax provisions of the Affordable Care Act (ACA), including the premium tax credit, see www.irs.gov/Affordable-Care-Act/Individuals-and-Families or call the IRS Healthcare Hotline for ACA questions (800-919-0452).

VOID box. If the “VOID” box is checked at the top of the form, you previously received a Form 1095-A for the policy described in Part I. That Form 1095-A was sent in error. You shouldn’t have received a Form 1095-A for this policy. Don’t use the information on this or the previously received Form 1095-A to figure your premium tax credit on Form 8962.

CORRECTED box. If the “CORRECTED” box is checked at the top of the form, use the information on this Form 1095-A to figure the premium tax credit and reconcile any advance credit payments on Form 8962. Don’t use the information on the original Form 1095-A you received for this policy.

Part I. Recipient Information, lines 1–15. Part I reports information about you, the insurance company that issued your policy, and the Marketplace where you enrolled in the coverage.

Line 1. This line identifies the state where you enrolled in coverage through the Marketplace.

Line 2. This line is the policy number assigned by the Marketplace to identify the policy in which you enrolled. If you are completing Part IV of Form 8962, enter this number on line 30, 31, 32, or 33, box a.

Line 3. This is the name of the insurance company that issued your policy.

Line 4. You are the recipient because you are the person the Marketplace identified at enrollment who is expected to file a tax return and who, if qualified, would take the premium tax credit for the year of coverage.

Line 5. This is your social security number (SSN). For your protection, this form may show only the last four digits. However, the Marketplace has reported your complete SSN to the IRS.

Line 6. A date of birth will be entered if there is no SSN on line 5.

Lines 7, 8, and 9. Information about your spouse will be entered only if advance credit payments were made for your coverage. The date of birth will be entered on line 9 only if line 8 is blank.

Lines 10 and 11. These are the starting and ending dates of the policy. Lines 12 through 15. Your address is entered on these lines.

Part II. Covered Individuals, lines 16–20. Part II reports information about each individual who is covered under your policy. This information includes the name, SSN, date of birth, and the starting and ending dates of coverage for each covered individual. For each line, a date of birth is reported in column C only if an SSN isn’t entered in column B.

If advance credit payments are made, the only individuals listed on Form 1095-A will be those whom you certified to the Marketplace would be in your tax family for the year of coverage (yourself, spouse, and dependents). If you certified to the Marketplace at enrollment that one or more of the individuals who enrolled in the plan aren’t individuals who would be in your tax family for the year of coverage, those individuals won’t be listed on your Form 1095-A. For example, if you indicated to the Marketplace at enrollment that an individual enrolling in the policy is your adult child who will not be your dependent for the year of coverage, that child will receive a separate Form 1095-A and won’t be listed in Part II on your Form 1095-A.

If advance credit payments are made and you certify that one or more enrolled individuals aren’t individuals who would be in your tax family for the year of coverage, your Form 1095-A will include coverage information in Part III that is applicable solely to the individuals listed on your Form 1095-A, and separately issued Forms 1095-A will include coverage information, including dollar amounts, applicable to those individuals not in your tax family.

If advance credit payments weren’t made and you didn’t identify at enrollment the individuals who would be in your tax family for the year of coverage, Form 1095-A will list all enrolled individuals in Part II on your Form 1095-A.

If there are more than 5 individuals covered by a policy, you will receive one or more additional Forms 1095-A that continue Part II.

Part III. Coverage Information, lines 21–33. Part III reports information about your insurance coverage that you will need to complete Form 8962 to reconcile advance credit payments or to take the premium tax credit when you file your return.

Column A. This column is the monthly premiums for the plan in which you or family members were enrolled, including premiums that you paid and premiums that were paid through advance payments of the premium tax credit. If you or a family member enrolled in a separate dental plan with pediatric benefits, this column includes the portion of the dental plan premiums for the pediatric benefits. If your plan covered benefits that aren’t essential health benefits, such as adult dental or vision benefits, the amount in this column will be reduced by the premiums for the nonessential benefits. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for these months regardless of whether advance credit payments were made for these months.

Column B. This column is the monthly premium for the second lowest cost silver plan (SLCSP) that the Marketplace has determined applies to members of your family enrolled in the coverage. The applicable SLCSP premium is used to compute your monthly advance credit payments and the premium tax credit you take on your return. See the instructions for Form 8962, Part II, on how to use the information in this column or how to complete Form 8962 if there is no information entered. If the policy was terminated by your insurance company due to nonpayment of premiums for 1 or more months, then a -0- will appear in this column for the months, regardless of whether advance credit payments were made for these months.

Column C. This column is the monthly amount of advance credit payments that were made to your insurance company on your behalf to pay for all or part of the premiums for your coverage. If this is the only column in Part III that is filled in with an amount other than zero for a month, it means your policy was terminated by your insurance company due to nonpayment of premiums, and you aren’t entitled to take the premium tax credit for that month when you file your tax return. You must still reconcile the entire advance payment that was paid on your behalf for that month using Form 8962. No information will be entered in this column if no advance credit payments were made.

Lines 21–33. The Marketplace will report the amounts in columns A, B, and C on lines 21–32 for each month and enter the totals on line 33. Use this information to complete Form 8962, line 11 or lines 12–23.

Understanding IRS 1095-A

What is the IRS 1095-A form?

The IRS 1095-A form is a tax document that provides information about your health insurance coverage obtained through the Health Insurance Marketplace. It includes details such as the months you were covered, the premiums you paid, and any premium tax credits you received. This form is crucial for filing your federal tax return accurately, especially if you received assistance with your health insurance costs.

Who receives a 1095-A form?

If you enrolled in a health insurance plan through the Health Insurance Marketplace, you should receive a 1095-A form. This applies to individuals and families who purchased coverage during the open enrollment period or who qualified for a Special Enrollment Period. If you did not enroll in a Marketplace plan, you will not receive this form.

When will I receive my 1095-A form?

The IRS requires that 1095-A forms be sent out by January 31 of the year following the coverage year. For example, if you had coverage in 2023, you should expect to receive your form by January 31, 2024. It can be sent via mail or made available electronically, depending on how you opted to receive your documents.

How do I use the 1095-A form when filing my taxes?

You will need the information from your 1095-A form to complete your federal tax return. Specifically, you will use it to fill out Form 8962, which calculates your premium tax credit and reconciles any advance payments of the credit you may have received. Make sure to double-check the information on the 1095-A for accuracy before using it for your tax filing.

What should I do if my 1095-A form is incorrect?

If you notice any discrepancies on your 1095-A form, such as incorrect coverage dates or premium amounts, contact the Health Insurance Marketplace where you obtained your coverage. They can issue a corrected form if necessary. It’s important to resolve any errors before filing your taxes to avoid complications or delays.

Can I access my 1095-A form online?

Yes, you can access your 1095-A form online through your Health Insurance Marketplace account. Log in to your account, and you should be able to find your tax documents in the “Documents” section. This can be a convenient way to obtain your form if you prefer not to wait for it to arrive by mail.

What happens if I don’t receive my 1095-A form?

If you do not receive your 1095-A form by early February and believe you should have, reach out to the Health Insurance Marketplace. It’s essential to obtain this form for your tax filing. If you cannot get a copy in time, you may need to estimate your premium tax credit based on your records, but be prepared to explain the situation if necessary.

Is the information on the 1095-A form confidential?

Yes, the information on your 1095-A form is confidential and protected by privacy laws. It contains personal details about your health insurance coverage and financial information. Always handle this document with care, and ensure it is stored securely to prevent unauthorized access.

How to Use IRS 1095-A

Once you have gathered the necessary information, you can proceed to fill out the IRS 1095-A form. This form will require specific details about your health coverage and the premiums you paid. Ensure that you have your health insurance information readily available, as it will make the process smoother.

Obtain the IRS 1095-A form. This can typically be downloaded from the IRS website or provided by your health insurance marketplace.
Fill in your personal information at the top of the form, including your name, address, and Social Security number.
Locate the section for "Coverage Information." Here, you will enter the details of your health coverage for the tax year.
Identify the months you had coverage. Mark each month that you were enrolled in a qualified health plan.
Fill in the premiums for your coverage. This information is often provided by your insurance provider and should reflect the amounts paid during the year.
If applicable, indicate any premium tax credits you received. This will help determine your tax obligations or refunds.
Review the completed form for accuracy. Ensure all information is correct and that there are no omissions.
Sign and date the form. This confirms that the information provided is true and accurate to the best of your knowledge.
Keep a copy of the completed form for your records. This will be important for your tax filing.