﻿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.

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Department of the Treasury
Internal Revenue Service
OMB No. 1545-2232

-- VOID
-- CORRECTED

Form 1095-A
2023
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.

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 ----

Part II Covered Individuals

16
A. Covered individual name ----
B. Covered individual SSN ----
C. Covered individual date of birth ----
D. Coverage start date ----
E. Coverage termination date ----
17
A. Covered individual name ----
B. Covered individual SSN ----
C. Covered individual date of birth ----
D. Coverage start date ----
E. Coverage termination date ----
18
A. Covered individual name ----
B. Covered individual SSN ----
C. Covered individual date of birth ----
D. Coverage start date ----
E. Coverage termination date ----
19
A. Covered individual name ----
B. Covered individual SSN ----
C. Covered individual date of birth ----
D. Coverage start date ----
E. Coverage termination date ----
20
A. Covered individual name ----
B. Covered individual SSN ----
C. Covered individual date of birth ----
D. Coverage start date ----
E. Coverage termination date ----

Part III Coverage Information

Month

21 January
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
22 February
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
23 March
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
24 April
25 May
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
26 June
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
27 July
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
28 August
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
29 September
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
30 October
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
31 November
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
32 December
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----
33 Annual Totals
A. Monthly enrollment premiums ----
B. Monthly second lowest cost silver plan (SLCSP) premium ----
C. Monthly advance payment of premium tax credit ----

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.
Cat. No. 60703Q
Form 1095-A (2023) 

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Form 1095-A (2023) 
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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 five 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. See the instructions for Form 8962, Part II, on how to complete Form 8962 if -0- is reported for 1 or more 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, the information is incorrect, or the information is reported as -0-. 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.

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Department of the Treasury
Internal Revenue Service
Sep 29, 2023
Cat. No. 63016Q

2023
Instructions for Form 1095-A
Health Insurance Marketplace Statement

Section references are to the Internal Revenue Code unless otherwise noted.

Future Developments

For the latest information about developments related to Form 1095-A and its instructions, such as legislation enacted after they were published, go to IRS.gov/Form1095A.

Additional Information

For information related to the Affordable Care Act, visit IRS.gov/ACA.

For additional information related to Form 1095-A, visit IRS.gov/Affordable-Care-Act/Individuals-And-Families/ Health-Insurance-Marketplace-Statements.

General Instructions

Purpose of Form

Form 1095-A is used to report certain information to the IRS about individuals who enroll in a qualified health plan through the Health Insurance Marketplace. Form 1095-A is also furnished to individuals to allow them to take the premium tax credit, to reconcile the credit on their returns with advance payments of the premium tax credit (advance credit payments), and to file an accurate tax return.

Who Must File

Health Insurance Marketplaces must file Form 1095-A to report information on all enrollments in qualified health plans in the individual market through the Marketplace. Do not file a Form 1095-A for a catastrophic health plan or a separate dental policy (called a stand-alone dental plan in these instructions).

When To File

File the annual report with the IRS and furnish the statements to individuals on or before January 31, 2024, for coverage in calendar year 2023.

The requirement to furnish a statement to individuals will be met if the Form 1095-A is properly addressed and mailed or furnished electronically (if the recipient has consented to electronic receipt) on or before the due date. If the regular due date falls on a Saturday, Sunday, or legal holiday, furnish the statement by the next business day. A business day is any day that isn't a Saturday, Sunday, or legal holiday.

How To File

Electronic filing. You must submit the information to the IRS electronically. Submit the information through the Department of Health and Human Services Data Services Hub.

Statements to Individuals

Furnishing required information to the individual. Marketplaces use Form 1095-A to furnish the required statement to recipients. A separate Form 1095-A must be furnished for each policy, and the information on the Form 1095-A should relate only to that policy. If two or more tax filers are enrolled in one policy, each tax filer receives a statement reporting coverage of only the members of that tax filer's tax family (a tax family may include the tax filer, the tax filer's spouse if the tax filer is filing a joint return with his or her spouse, and the tax filer's dependents). See the instructions for line 4 for more information about who is a recipient. Don't furnish a Form 1095-A for a catastrophic health plan or a stand-alone dental plan. See the instructions for Part III, column A.

On Form 1095-A statements furnished to recipients, filers of Form 1095-A may truncate the social security number (SSN) of an individual receiving coverage by showing only the last four digits of the SSN and replacing the first five digits with asterisks (*) or Xs. Truncation isn't allowed on forms filed with the IRS.

Statements must be furnished to recipients on paper by mail, unless a 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.

Consent to furnish 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. A recipient may provide her or his consent on paper or electronically, such as by email. If consent is provided on paper, the recipient must confirm the consent electronically. An electronic statement may be furnished by email or by informing the recipient how to access the statement on a Marketplace's website (for example, in the recipient's Marketplace account).

Specific Instructions

Part I-Recipient Information

Line 1. Enter the Marketplace state name or abbreviation.

Line 2. Enter the number the Marketplace assigned to the policy. If the policy number is greater than 15 characters, enter only the last 15 characters.

Line 3. Enter the name of the issuer of the policy.

Line 4. Enter the name of the recipient of the statement. This should be the person identified at enrollment as the tax filer (the person who is expected to file a tax return, to

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claim other family members as dependents, and who, if qualified, would take the premium tax credit for the year of coverage for his or her tax family). If the tax filer can't be identified from the information provided at enrollment (for example, because no financial assistance was requested), enter the name of the primary applicant for the coverage.

Line 5. Enter the social security number (SSN) for the recipient shown on line 4.

Line 6. Enter the recipient's date of birth only if line 5 is blank.

Lines 7, 8, and 9. Enter information about the recipient's spouse, if the recipient has one, if advance credit payments were made for the coverage. Enter this information even if the advance credit payments were not made for the spouse's coverage. Enter a date of birth only if line 8 is blank.

Line 10. Enter the date that coverage under the policy started. If the policy was in effect at the start of the year, enter 1/1/2023.

Line 11. Enter the date of termination if the policy was terminated during the year. If the policy was in effect at the end of the year, enter 12/31/2023.

Lines 12-15. Enter the recipient's address.

Part II-Covered Individuals

Enter on lines 16 through 20 and columns A through E information for each individual covered under the policy, including the recipient and the recipient's spouse, if covered. If advance credit payments were not made for any coverage under the policy and a tax family cannot be identified, enter in Part II information for all covered individuals. If advance credit payments were made for the coverage or a tax family can be identified, enter in Part II information only for covered individuals whom the tax filer certified at enrollment would be a part of the tax filer's tax family. Information about individuals enrolled in the same policy as the tax filer's tax family who are not members of that tax family, including children, must be reported on a separate Form 1095-A.

For each line, enter a date of birth in column C only if column B is blank. Enter in column D the date the coverage started for the individual. Enter in column E the date of termination if the individual's coverage was terminated during the year. If the coverage was in effect at the end of the year, enter 12/31/2023.

TIP If there are more than five covered individuals, complete one or more additional Forms 1095-A, Part II.

Part III-Coverage Information

Enter information in Part III, lines 21 through 32, for each month of coverage. This information is determined on a monthly basis and may change during the year if there is a change in enrollment or other circumstances that affect eligibility for, or the amount of, the premium tax credit. Total the amounts on lines 21 through 32 and enter on line 33.

Column A. Enter the total monthly enrollment premiums for the policy in which the covered individuals enrolled. Include only the premiums allocable to essential health benefits. If a covered individual is enrolled in a stand-alone dental plan, include the portion of the premiums for the stand-alone dental plan that is allocable to pediatric dental coverage in the total monthly enrollment premiums. If more than one Form 1095-A is filed for coverage of the recipient's family for the same months because, for example, a family member enrolled in a separate policy, include the portion of the premium for pediatric dental coverage in the amount in column A on only one Form 1095-A. If more than one tax filer is enrolled in a policy, report on each tax filer's Form 1095-A only those enrollment premiums allocated to that tax filer. If a policy is terminated by an issuer for nonpayment of premiums, enter -0- for a month in which the covered individuals have coverage but the premiums are not fully paid (generally, the first month of a grace period). If one or more covered individuals terminate coverage before the last day of a month, the amount reported in this column should not include any amount of the monthly enrollment premium that was refunded. If the issuer provided a premium credit for one or more months, the amount reported in this column should be the amount of the monthly enrollment premium as reduced by any premium credit.

Column B. Enter the premiums for the applicable second lowest cost silver plan (SLCSP) that was used as a benchmark to compute monthly advance credit payments. If advance payments were made, the applicable SLCSP for a month is the SLCSP that applies to individuals in Part II who were identified at enrollment as members of the tax filer's tax family (the tax filer, the tax filer's spouse if the tax filer is filing a joint return with her or his spouse, and any dependents of the tax filer) and who are enrolled in the coverage on the first day of the month and are not eligible for other health coverage for that month. However, if an individual enrolls in coverage and the enrollment is effective on the date of the individual's birth, adoption, placement in foster care, or on the effective date of a court order, the individual should be considered to have enrolled on the first day of the month for purposes of the applicable SLCSP premium reported in column B. If all covered individuals enroll after the first of the month, and no individual's coverage is effective on the date of the individual's birth, adoption, placement in foster care, or on the effective date of a court order, enter -0- in column B for that month. If more than one Form 1095-A is filed for coverage of a tax filer's family for the same month (for example, because members of the family were split among several policies), enter the SLCSP premium that applies to all the family members who were enrolled in any policy on the first of the month and who were not eligible for other health coverage for that month. Enter this SLCSP premium in column B on each Form 1095-A.

In some cases, the information provided at enrollment may not indicate which covered individuals are members of the recipient's family and are not eligible for other health coverage. (Such information may not be provided, for example, because no financial assistance was requested.) If this is the case, and if the Marketplace has

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provided a tool for determining the applicable SLCSP premium for the year of coverage at the time of filing the tax return, leave column B blank. If the Marketplace has not provided a tool for determining the applicable SLCSP premium, enter the premiums for the SLCSP that would apply to all individuals identified in Part II as covered for the month.

If a policy is terminated by an issuer for nonpayment of premiums and advance credit payments are made, enter -0- for a month in which the covered individuals have coverage but the premiums are not paid (generally, the first month of a grace period). However, if an individual enrolled on the first day of a month terminates coverage before the last day of the month, the individual should be considered to have been enrolled for the entire month for purposes of the applicable SLCSP premium reported in column B.

Column C. Enter the amount of advance credit payments for the month. If more than one Form 1095-A is filed for coverage of a tax filer's family for the same months, enter only the advance credit payment amount allocated to the policy reported on this Form 1095-A. If the tax filer's family is also enrolled in a stand-alone dental plan, any advance credit payments allocated to the stand-alone dental plan should be added to the advance credit payments allocated to one of the policies reported on a Form 1095-A.

Void Statements

If a Form 1095-A was sent for a policy that shouldn't be reported on a Form 1095-A, such as a stand-alone dental plan or a catastrophic health plan, send a duplicate of that Form 1095-A and check the VOID box at the top of the form. Provide this information to the IRS and to the recipient of the statement as soon as possible after discovering that the statement was sent in error.

Correction to Information Reported

Report corrected information on the Form 1095-A to the IRS and to the recipient as soon as possible after discovering that information reported is incorrect. Check the CORRECTED box on the top of the form.

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. You are required by the Internal Revenue Code to give us the information. We need it to ensure that taxpayers are complying with these laws and to allow us to figure and collect the right amount of tax.

You are not 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.

The time needed to complete and file this form will vary depending on individual circumstances. The estimated average time is:

Preparing the form 3 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.
