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Department of the Treasury
Internal Revenue Service
2023

Instructions for Forms

1094-C and 1095-C

Section references are to the Internal Revenue Code unless report information about each employee to the IRS and to the
otherwise noted. employee. Forms 1094-C and 1095-C are used in determining
whether an ALE Member owes a payment under the employer
Future Developments shared responsibility provisions under section 4980H. Form
For the latest information about developments related to Form 1095-C is also used in determining the eligibility of employees
1094-C, Transmittal of Employer-Provided Health Insurance for the premium tax credit.
Offer and Coverage Information Returns, and Form 1095-C, ALE Members that offer employer-sponsored, self-insured
Employer-Provided Health Insurance Offer and Coverage, and coverage also use Form 1095-C to report information to the IRS
the instructions, such as legislation enacted after they were and to employees about individuals who have minimum essential
published, go to IRS.gov/Form1094C and IRS.gov/Form1095C. coverage under the employer plan.

What’s New Who Must File
The electronic-filing threshold for information returns required to An ALE Member must file one or more Forms 1094-C (including
be filed on or after January 1, 2024, has been decreased to 10 or a Form 1094-C designated as the Authoritative Transmittal,
more returns. See Electronic Filing, later. whether or not filing multiple Forms 1094-C), and must file a
Form 1095-C for each employee who was a full-time employee
Additional Information of the ALE Member for any month of the calendar year.
For information related to the Affordable Care Act, visit IRS.gov/ Generally, the ALE Member is required to furnish a copy of the
ACA. For the final regulations under section 6056, Information Form 1095-C (or a substitute form) to the employee.
Reporting by Applicable Large Employers on Health Insurance
Coverage Offered Under Employer-Sponsored Plans, see T.D. An ALE Member is, generally, a single person or entity that is
9661, 2014-13 I.R.B. 855, at IRS.gov/irb/2014-13_IRB/ar09.html. an Applicable Large Employer, or if applicable, each person or
For the final regulations under section 6055, Information entity that is a member of an Aggregated ALE Group. An
Reporting of Minimum Essential Coverage, see T.D. 9660, Applicable Large Employer, generally, is an employer with 50 or
2014-13 I.R.B. 842, at IRS.gov/irb/2014-13_IRB/ar08.html and more full-time employees (including full-time equivalent
T.D. 9970, 2023-02 I.R.B. 311, at IRS.gov/irb/2023-02_IRB. For employees) in the previous year. For purposes of determining if
the final regulations under section 4980H, Shared Responsibility an employer or group of employers is an Applicable Large
for Employers Regarding Health Coverage, see T.D. 9655, Employer, all ALE Members under common control (an
2014-9 I.R.B. 541, at IRS.gov/irb/2014-9_IRB/ar05.html. For Aggregated ALE Group) are aggregated together. If the
answers to frequently asked questions regarding the employer Aggregated ALE Group, taking into account the employees of all
shared responsibility provisions and related information reporting ALE Members in the group, employed on average 50 or more
requirements, visit IRS.gov. full-time employees (including full-time equivalent employees) on
business days during the preceding calendar year, then the
For information related to filing Forms 1094-C and 1095-C Aggregated ALE Group is an Applicable Large Employer and
electronically, visit IRS.gov/AIR. For FAQs specifically related to each separate employer within the group is an ALE Member.
completing Forms 1094-C and 1095-C, go to IRS.gov/ Each ALE Member is required to file Forms 1094-C and 1095-C
Affordable-Care-Act/Employers/Questions-and-Answers-about- reporting offers of coverage to its full-time employees (even if the
Information-Reporting-by-Employers-on-Form-1094-C-and- ALE Member has fewer than 50 full-time employees of its own).
Form-1095-C.
For more information on which employers are subject to the
For additional guidance and proposed regulatory changes employer shared responsibility provisions of section 4980H, see
relating to section 6055, including the requirement to solicit the Employer in the Definitions section of these instructions. For
TIN of each covered individual for purposes of the reporting of more information on determining full-time employees, see
health coverage information, see Proposed Regulations section Full-Time Employee in the Definitions section of these
1.6055-1(h) and Regulations section 301.6724-1. instructions, which includes information on the treatment of new
hires and employees in Limited Non-Assessment Periods.
General Instructions for For purposes of reporting on Forms 1094-C and 1095-C,
TIP an employee in a Limited Non-Assessment Period is not
Forms 1094-C and 1095-C considered a full-time employee during that period.
See Definitions, later, for key terms used in these instructions.

Purpose of Form Reporting by Employers That
Employers with 50 or more full-time employees (including Sponsor Self-Insured Health Plans
full-time equivalent employees) in the previous year use Forms
1094-C and 1095-C to report the information required under An employer that offers health coverage through a self-insured
sections 6055 and 6056 about offers of health coverage and health plan must report information about each individual
enrollment in health coverage for their employees. Form 1094-C enrolled in such coverage. For an employer that is an ALE
must be used to report to the IRS summary information for each Member, this information must be reported on Form 1095-C, Part
Applicable Large Employer (ALE Member) (defined below) and III, for any employee who is enrolled in coverage (and any
to transmit Forms 1095-C to the IRS. Form 1095-C is used to spouse or dependent of that employee). See the option to file

Sep 26, 2023 Cat. No. 63018M

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Form 1094-B and Form 1095-B, rather than Form 1094-C and                Substitute Statements to Recipients
Form 1095-C, to report coverage of certain non-employees,               If you are not using the official IRS form to furnish statements to 
below.                                                                  recipients, see Pub. 5223, General Rules and Specifications for 
                                                                        Affordable Care Act Substitute Forms 1095-A, 1094-B, 1095-B, 
ALE Members that offer health coverage through an                       1094-C, and 1095-C, which explains the requirements for format 
employer-sponsored, self-insured health plan must complete              and content of substitute statements to recipients. You may 
Form 1095-C, Parts I, II, and III, for any employee who enrolls in      develop them yourself or buy them from a private printer. 
the health coverage, whether or not the employee is a full-time         Substitute statements furnished to recipients may be in portrait 
employee for any month of the calendar year.                            format; however, substitute returns filed with the IRS using paper 
                                                                        must be printed in landscape format.
For full-time employees enrolled in an ALE Member’s 
self-insured coverage, including an employee who was a                  Authoritative Transmittal for ALE
full-time employee for at least 1 month of the calendar year, the 
ALE Member must complete Form 1095-C, Part II, according to             Members Filing Multiple Forms 1094-C
the generally applicable instructions, and should not enter code        A Form 1094-C must be filed when an ALE Member files one or 
1G on line 14 for any month. For an employee enrolled in an ALE         more Forms 1095-C. An ALE Member may choose to file 
Member’s self-insured coverage who is not a full-time employee          multiple Forms 1094-C, each accompanied by Forms 1095-C for 
for any month of the calendar year (meaning that for all 12             a portion of its employees, provided that a Form 1095-C is filed 
calendar months the employee was not a full-time employee), for         for each employee for whom the ALE Member is required to file. 
Form 1095-C, Part II, the ALE Member must enter code 1G on              If an ALE Member files more than one Form 1094-C, one (and 
line 14 in the “All 12 Months” column or in the separate monthly        only one) Form 1094-C filed by the ALE Member must be 
boxes for all 12 calendar months, and the ALE Member need not           identified on line 19, Part I, as the Authoritative Transmittal, and, 
complete Part II, lines 15 and 16.                                      on the Authoritative Transmittal, the ALE Member must report 
                                                                        certain aggregate data for all full-time employees and all 
       An individual coverage HRA is a self-insured group               employees, as applicable, of the ALE Member.
TIP    health plan and is therefore an eligible 
       employer-sponsored plan. An individual is ineligible for a       Example 1.       Employer A, an ALE Member, files a single Form 
premium tax credit (PTC) for a month if the individual is covered       1094-C, attaching Forms 1095-C for each of its 100 full-time 
by an individual coverage HRA or eligible for an individual             employees. This Form 1094-C should be identified as the 
coverage HRA that is affordable.                                        Authoritative Transmittal on line 19, and the remainder of the 
                                                                        form completed as indicated in the instructions for line 19, later.
An employer that offers employer-sponsored, self-insured                Example 2.       Employer B, an ALE Member, files two Forms 
health coverage but is not an ALE Member should not file Forms          1094-C, one for each of its two operating divisions, Division X 
1094-C and 1095-C, but should instead file Forms 1094-B and             and Division Y. (Division X and Division Y are units of the same 
1095-B to report information for employees who enrolled in the          ALE Member, and thus both report under the same employer 
employer-sponsored, self-insured health coverage.                       identification number (EIN); they are not members of an 
                                                                        Aggregated ALE Group.) Attached to one Form 1094-C are 
Note. If an ALE Member is offering health coverage to                   Forms 1095-C for the 200 full-time employees of Division X, and 
employees other than under a self-insured plan, such as through         attached to the other Form 1094-C are Forms 1095-C for the 
an insured health plan or a multiemployer health plan, the issuer       1,000 full-time employees of Division Y. One of these Forms 
of the insurance or the sponsor of the plan providing the               1094-C should be identified as the Authoritative Transmittal on 
coverage is required to furnish the information about their health      line 19, and should include aggregate employer-level data for all 
coverage to any enrolled employees, and the ALE Member                  1,200 full-time employees of Employer B as well as the total 
should not complete Form 1095-C, Part III, for those employees.         number of employees of Employer B, as applicable, as required 
                                                                        in Parts II, III, and IV of Form 1094-C. The other Form 1094-C 
                                                                        should not be identified as the Authoritative Transmittal on 
Reporting of Enrollment Information                                     line 19, and should report on line 18 only the number of Forms 
for Non-Employees: Option                                               1095-C that are attached to that Form 1094-C, and should leave 
To Use Forms 1094-B and 1095-B                                          the remaining sections of the form blank, as indicated in the 
                                                                        instructions for line 19, later.
ALE Members that offer employer-sponsored, self-insured 
health coverage to non-employees who enroll in the coverage             Note. Each ALE Member must file its own Forms 1094-C and 
may use Forms 1094-B and 1095-B, rather than Form 1095-C,               1095-C under its own separate EIN, even if the ALE Member is 
Part III, to report coverage for those individuals and other family     part of an Aggregated ALE Group. No Authoritative Transmittal 
members. For this purpose, a non-employee includes, for                 should be filed for an Aggregated ALE Group.
example, a non-employee director, an individual who was a               Example 3.       Assume that Employer A from Example 1 is a 
retired employee during the entire year, or a non-employee              member of the same Aggregated ALE Group as Employer B 
COBRA beneficiary, including a former employee who                      from Example 2. Accordingly, Employer A and Employer B are 
terminated employment during a previous year.                           separate ALE Members filing under separate EINs. Forms 
                                                                        1094-C should be filed in the same manner indicated in 
For information on reporting for non-employees enrolled in an           Examples 1 and  . Employer A should include only information 2
employer-sponsored, self-insured health plan using Forms                about employees of Employer A in its Authoritative Transmittal, 
1094-B and 1095-B, see the instructions for those forms.                and Employer B should include only information about 
                                                                        employees of Employer B in its Authoritative Transmittal. No 
For ALE Members that choose to use Form 1095-C to report                Authoritative Transmittal should be filed for the Aggregated ALE 
coverage information for non-employees enrolled in an                   Group reporting combined data for employees of both Employer 
employer-sponsored, self-insured health plan, see the specific          A and Employer B.
instructions for Form 1095-C, Part III—Covered Individuals 
(Lines 18–30), later. Form 1095-C may be used only if the               Similar rules apply for a Governmental Unit that has 
individual identified on line 1 has an SSN.                             delegated its reporting responsibilities for some of its employees 

                                                                    -2-       Instructions for Forms 1094-C and 1095-C (2023)

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to another Governmental Unit—see Designated Governmental employees reported for those months on Form 1094-C. For the
Entity (DGE) in the Definitions section of these instructions for months April through December, on Form 1095-C, Employer A
more information. In the case of a Governmental Unit that has should enter code 1H (no offer of coverage) on line 14, leave
delegated its reporting responsibilities for some of its employees, line 15 blank, and enter code 2A (not an employee) on line 16
the Governmental Unit must ensure that among the multiple (since Employee is treated as an employee of Employer B and
Forms 1094-C filed by or on behalf of the Governmental Unit not as an employee of Employer A in those months), and should
transmitting Forms 1095-C for the Governmental Unit’s exclude Employee from the count of total employees and
employees, one of the filed Forms 1094-C is designated as the full-time employees reported for those months on Form 1094-C.
Authoritative Transmittal and reports aggregate employer-level
data for the Governmental Unit, as required in Parts II, III, and IV When To File
of Form 1094-C. You will meet the requirement to file Forms 1094-C and 1095-C if
Example. County is an Aggregated ALE Group made up of the forms are properly addressed and mailed on or before the
the ALE Members School District, the Police District, and the due date. If the due date falls on a weekend or legal holiday, then
County General Office. The School District designates the state the due date is the following business day. A business day is any
to report on behalf of the teachers and reports for itself for its day that is not a Saturday, Sunday, or legal holiday.
remaining full-time employees. In this case, either the School Generally, you must file Forms 1094-C and 1095-C by
District or the state must file an Authoritative Transmittal February 28 if filing on paper (or March 31 if filing electronically)
reporting aggregate employer-level data for the School District. of the year following the calendar year to which the return
relates. For calendar year 2023, Forms 1094-C and 1095-C are
One Form 1095-C for Each required to be filed by February 28, 2024, or April 1, 2024, if filing
Employee of ALE Member electronically.
For each full-time employee of an ALE Member, there must be
See Furnishing Forms 1095-C to Employees for information
only one Form 1095-C filed for employment with that ALE
on when Form 1095-C must be furnished.
Member. For example, if an ALE Member separately reports for
each of its two divisions, the ALE Member must combine the
offer and coverage information for any employee who worked at Extensions
both divisions during the calendar year so that a single Form
1095-C is filed for the calendar year for that employee, which You can get an automatic 30-day extension of time to file by
reports information for all 12 months of the calendar year from completing Form 8809, Application for Extension of Time To File
that ALE Member. Information Returns. The form may be submitted on paper, or
through the FIRE System either as a fill-in form or an electronic
In contrast, a full-time employee who works for more than one file. No signature or explanation is required for the extension.
ALE Member that is a member of the same Aggregated ALE However, you must file Form 8809 on or before the due date of
Group must receive a separate Form 1095-C from each ALE the returns in order to get the 30-day extension. Under certain
Member. For any calendar month in which a full-time employee hardship conditions, you may apply for an additional 30-day
works for more than one ALE Member of an Aggregated ALE extension. See the Instructions for Form 8809 for more
Group, only one ALE Member is treated as the employer of that information.
employee for reporting purposes (generally, the ALE Member for
whom the employee worked the greatest number of hours of How to apply. File Form 8809 as soon as you know that a
service), and only that ALE Member reports for that employee for 30-day extension of time to file is needed. See the instructions
that calendar month. The other ALE Member is not required to for Form 8809. Mail or fax Form 8809 using the address and
report for that employee for that calendar month, unless the phone number listed in the instructions. You can also submit the
other ALE Member is otherwise required to file Form 1095-C for extension request online through the FIRE System. You are
that employee because the individual was a full-time employee encouraged to submit requests using the online fill-in form. See
of that ALE Member for a different month of the same calendar Pub. 1220 for more information on filing online or electronically.
year. In this case, the individual may be treated as not employed
by that ALE Member for that calendar month. If under these Where To File
rules, an ALE Member is not required to report for an employee Send all information returns filed on paper to the following:
for any month in the calendar year, the ALE Member is not
required to report for that full-time employee for that calendar If your principal business,
year. For a description of the rules related to determining which office or agency, or legal
Use the following address:
ALE Member in an Aggregated ALE Group is treated as the residence, in the case of an
employer for a month in this situation, see the definition of individual, is located in:
Employee. ▼ ▼
Example. Employer A and Employer B are separate ALE
Members that belong to the same Aggregated ALE Group. Both Alabama, Arizona, Arkansas,
Employer A and Employer B offer coverage through the AB Connecticut, Delaware, Florida,
health plan, which is an insured plan. In January and February, Georgia, Kentucky, Louisiana,
Employee has 130 hours of service for Employer A and no hours Maine, Massachusetts, Department of the Treasury
of service for Employer B. In March, Employee has 100 hours of Mississippi, New Hampshire, Internal Revenue Service
service for Employer A and 30 hours of service for Employer B. New Jersey, New Mexico, New Center
In April through December, Employee has 130 hours of service York, North Carolina, Ohio, Austin, TX 73301
for Employer B and no hours of service for Employer A. Pennsylvania, Rhode Island,
Employer A is the employer of Employee for filing purposes for Texas, Vermont, Virginia,
January, February, and March. Employer A should file Form West Virginia
1095-C for Employee reporting offers of coverage using the
appropriate code on line 14 for January, February, and March;
should complete lines 15 and 16 per the instructions; and should
include Employee in the count of total employees and full-time
Instructions for Forms 1094-C and 1095-C (2023) -3-

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If your principal business, you establish reasonable cause. However, you can file up to 10
office or agency, or legal returns on paper; those returns will not be subject to a penalty for
Use the following address:
residence, in the case of an failure to file electronically. The penalty applies separately to
individual, is located in: original returns and corrected returns.
▼ ▼ Pub. 5165, Guide for Electronically Filing Affordable Care Act
(ACA) Information Returns for Software Developers and
Alaska, California, Colorado, Transmitters, specifies the communication procedures,
District of Columbia, Hawaii, transmission formats, business rules, and validation procedures,
Idaho, Illinois, Indiana, Iowa, and explains when a return will be accepted, accepted with
Department of the Treasury
Kansas, Maryland, Michigan, errors, or rejected, for returns filed electronically for calendar
Internal Revenue Service
Minnesota, Missouri, Montana, year 2023 through the ACA Information Return (AIR) system. To
Center
Nebraska, Nevada, North develop software for use with the AIR system, software
P.O. Box 219256
Dakota, Oklahoma, Oregon, developers, transmitters, and issuers, including ALE Members
Kansas City, MO 64121-9256
South Carolina, South Dakota, filing their own Forms 1094-C and 1095-C, should use the
Tennessee, Utah, Washington, guidelines provided in Pub. 5165 along with the Extensible
Wisconsin, Wyoming Markup Language (XML) Schemas published on IRS.gov.
Reminder. The formatting directions in these instructions (for
example, the directions to enter the 9-digit EIN, including the
dash on line 2 of Form 1094-C) are for the preparation of paper
If your legal residence or principal place of business or returns. When filing forms electronically, the formatting set forth
principal office or agency is outside the United States, file with in the XML Schemas and Business Rules published on IRS.gov
the Department of the Treasury, Internal Revenue Service must be followed rather than the formatting directions in these
Center, Austin, TX 73301. instructions. For more information regarding electronic filing, see
Shipping and mailing. If you are filing on paper, send the Pubs. 5164 and 5165.
forms to the IRS in a flat mailing (not folded), and do not
paperclip or staple the forms together. If you are sending many Substitute Returns Filed With the IRS
forms, you may send them in conveniently sized packages. On If you are filing your returns on paper, see Pub. 5223 for
each package, write your name, number the packages specifications for private printing of substitute information
consecutively, and place Form 1094-C in package number one. returns. You may not request special consideration. Only forms
Postal regulations require forms and packages to be sent by that conform to the official form and the specifications in Pub.
First-Class Mail. Returns filed with the IRS must be printed in 5223 are acceptable for filing with the IRS. Substitute returns
landscape format. filed with the IRS must be printed in landscape format.
Keeping copies. Generally, keep copies of information returns
you filed with the IRS or have the ability to reconstruct the data VOID Box
for at least 3 years, from the due date of the returns. Do not use this box on Form 1095-C.

Electronic Filing Corrected Forms 1094-C and 1095-C
If you are required to file 10 or more For information about filing corrections electronically, see
information returns during the year, you TIP section 7.1 of Pub. 5165.
must file the forms electronically. The
10-or-more requirement applies in the aggregate to certain
information returns that are original or corrected returns. Corrected Returns
Accordingly, a filer may be required to file fewer than 10 Forms
1094-C and 1095-C, but still have an electronic filing obligation A corrected return should be filed as soon as possible after an
based on other kinds of information returns filed. The electronic error is discovered. File the corrected returns as follows.
filing requirement does not apply if you request and receive a
hardship waiver. The IRS encourages you to file electronically Form 1094-C. If correcting information on the Authoritative
even though you are filing fewer than 10 returns. Transmittal (identified on Part I, line 19, as the Authoritative
Transmittal, one (and only one) of which must be filed for each
Waiver. To receive a waiver from the required filing of ALE Member reporting aggregate employer-level data for all
information returns electronically, submit Form 8508. You are full-time employees and employees of the ALE Member), file a
encouraged to file Form 8508 at least 45 days before the due standalone, fully completed Form 1094-C, including the correct
date of the returns, but no later than the due date of the return. information, and enter an “X” in the “CORRECTED” checkbox.
The IRS does not process waiver requests until January 1 of the Do not file a return correcting information on a Form 1094-C that
calendar year the returns are due. You cannot apply for a waiver is not the Authoritative Transmittal.
for more than 1 tax year at a time. If you need a waiver for more Do not file any other documents (for example, Form
than 1 tax year, you must reapply at the appropriate time each ! 1095-C) with the corrected Authoritative Transmittal.
year. If a waiver for original returns is approved, any corrections CAUTION
for the same types of returns will be covered under the waiver. Form 1095-C. If correcting information on a Form 1095-C that
However, if you submit original returns electronically but you was previously filed with the IRS, file a fully completed Form
want to submit your corrections on paper, a waiver must be 1095-C, including the correct information and enter an “X” in the
approved for the corrections if you must file 10 or more “CORRECTED” checkbox. File a Form 1094-C (do not mark the
corrections. If you receive an approved waiver, do not send a “CORRECTED” checkbox on Form 1094-C) with corrected
copy of it to the service center where you file your paper returns. Form(s) 1095-C. Furnish the employee a copy of the corrected
Keep the waiver for your records only. Form 1095-C, unless the ALE Member was, and continues to be,
If you are required to file electronically but fail to do so, and eligible for and used the alternative method of furnishing under
you do not have an approved waiver, you may be subject to a the Qualifying Offer Method for that employee for that year’s
penalty of $310 per return for failure to file electronically unless furnishing. For more information, see Alternative method of

-4- Instructions for Forms 1094-C and 1095-C (2023)

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furnishing Form 1095-C to employees under the Qualifying Offer Original Authoritative Transmittal Form 1094-C
Method.
IF any of the following are THEN ...
Forms 1095-C filed with incorrect dollar amounts on line 15, incorrect ...
Employee Required Contribution, may fall under a safe harbor
for certain de minimis errors. The safe harbor generally applies if ALE Member or Designated 1. Prepare a new Authoritative
no single amount in error differs from the correct amount by more Government Entity (Name and/or Transmittal, Form 1094-C.
than $100. If the safe harbor applies, you will not have to correct EIN)
Form 1095-C to avoid penalties. However, if the recipient elects 2. Enter an “X” in the “CORRECTED”
for the safe harbor not to apply, you may have to issue a checkbox at the top of the form.
corrected Form 1095-C to avoid penalties. For more information, Total number of Forms 1095-C filed
see Notice 2017-9, 2017-4 I.R.B. 542, at IRS.gov/irb/2017-04 by and/or on behalf of ALE Member
IRB/ar11.html. 3. Submit the standalone corrected
Form 1094-C with the correct
Note. Enter an “X” in the “CORRECTED” checkbox only when information present.
correcting a Form 1095-C previously filed with the IRS. If you are Aggregated ALE Group Membership
correcting a Form 1095-C that was previously furnished to a
recipient, but not filed with the IRS, write, type, or print Certifications of Eligibility
“CORRECTED” on the new Form 1095-C furnished to the
recipient. Minimum Essential Coverage Offer
Indicator
Correcting information affecting statement furnished to
employee using an Alternative Furnishing Method under Section 4980H Full-Time Employee
the Qualifying Offer Method. If an ALE Member eligible to use Count for ALE Member
the Qualifying Offer Method had furnished the employee an
alternative statement, the ALE Member must furnish the Aggregated Group Indicator
employee a corrected statement if it filed a corrected Form
1095-C correcting the ALE Member’s name, EIN, address, or Other ALE Members of Aggregated
contact name and telephone number. If the ALE Member is no ALE Group (Name and/or EIN)
longer eligible to use an alternative furnishing method for the
employee for whom it filed a corrected Form 1095-C, it must
furnish a Form 1095-C to the employee and advise the employee
that Form 1095-C replaces the statement it had previously Original Form 1095-C Submitted to IRS and Furnished to Employee
furnished.
IF any of the following are THEN ...
If you fail to file correct information returns or fail to incorrect ...
! furnish a correct recipient statement, you may be subject
CAUTION to a penalty. However, you are not required to file
Name, SSN, ALE Member EIN 1. Prepare a new Form 1095-C.
corrected returns for missing or incorrect TINs if you meet the
reasonable cause criteria. For additional information, see Pub. Offer of Coverage (line 14) 2. Enter an “X” in the “CORRECTED”
1586, Reasonable Cause Regulations and Requirements for checkbox at the top of the form.
Missing and Incorrect Name/TINs on Information Returns.
Employee Required Contribution 3. Submit corrected Forms 1095-C with
See the charts for examples of errors and step-by-step a non-authoritative Form 1094-C
TIP instructions for filing corrected returns. transmittal to the IRS.
Section 4980H Safe Harbor and
Other Relief Codes (line 16)
4. Furnish a corrected Form 1095-C to
the employee.
Covered Individuals Information

Instructions for Forms 1094-C and 1095-C (2023) -5-

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Original Alternative Furnishing Method Under the Qualifying Offer A statement may be furnished electronically by email or by
Method Statement Furnished to Employee informing the individual how to access the statement on the ALE
Member’s website. Statements reporting coverage and offers of
IF any of the following are THEN ... coverage under an expatriate health plan, however, may be
incorrect ...
furnished electronically unless the recipient explicitly refuses to
consent to receive the statement in an electronic format. Specific
Name, SSN, ALE Member EIN • Submission to the IRS: information on consents to furnish statements electronically can
1. Prepare a new Form 1095-C. be found in Regulations section 301.6056-2.
Offer of Coverage 2. Enter an “X” in the “CORRECTED”
checkbox at the top of the form. Extensions of time to furnish statements to recipients. The
3. Submit corrected Form 1095-Cs due date for furnishing Form 1095-C is automatically extended
with a non-authoritative Form 1094-C from January 31, 2024, to March 1, 2024. Thus, no additional
transmittal to the IRS. extensions will be granted.
Information reporting penalties. All employers subject to the
• Furnish to employee: employer shared responsibility provisions and other employers
If, after the correction, the ALE Member that sponsor self-insured group health plans that fail to comply
is still eligible to use the alternative with the applicable information reporting requirements may be
furnishing method under the Qualifying subject to the general reporting penalty provisions for failure to
Offer Method, furnish the employee
either a Form 1095-C or corrected file correct information returns and failure to furnish correct
statement. payee statements. For returns required to be made and
If the ALE Member is no longer eligible statements required to be furnished for 2023 tax year returns, the
to use the alternative furnishing method following apply.
with respect to the employee, furnish a • The penalty for failure to file a correct information return is
Form 1095-C to the employee. $310 for each return for which the failure occurs, with the total
penalty for a calendar year not to exceed $3,783,000.
• The penalty for failure to provide a correct payee statement is
$310 for each statement for which the failure occurs, with the
Furnishing Forms 1095-C to Employees total penalty for a calendar year not to exceed $3,783,000.
• Special rules apply that increase the per-statement and total
You will meet the requirement to furnish Form 1095-C to an penalties if there is intentional disregard of the requirement to file
employee if the form is properly addressed and mailed on or the returns and furnish the required statements.
before the due date. If the due date falls on a weekend or legal
holiday, then the due date is the following business day. A Penalties may be waived if the failure was due to reasonable
business day is any day that is not a Saturday, Sunday, or legal cause and not willful neglect. See section 6724 and Regulations
holiday. section 301.6724-1 and Regulations section 1.6055-1(h) (which
relate to Form 1095-C, Part III). For additional information, see
An ALE member must furnish a Form 1095-C to each of its Pub. 1586.
full-time employees by March 1, 2024, for the 2023 calendar
year. See Extensions of time to furnish statements to recipients, Alternative manner of furnishing statements to
below. non-full-time employees. If you are an ALE member that offers
employer-sponsored, self-insured health coverage and meets
For more information on alternative furnishing methods for the requirements of Regulations section 1.6055-1(g), you may
employers, see Qualifying Offer Method, later. use the alternative manner of furnishing statements to
Filers of Form 1095-C may truncate the social security non-full-time employees and non-employees who are enrolled in
number (SSN) of an individual (the employee or any family the self-insured health coverage. To use the alternative manner
member of the employee receiving coverage) on Form 1095-C of furnishing statements, the following conditions must be met.
statements furnished to employees by showing only the last four • The employer must provide clear and conspicuous notice, in a
digits of the SSN and replacing the first five digits with asterisks location on its website that is reasonably accessible to all
(*) or Xs. Truncation is not allowed on forms filed with the IRS. In individuals, stating that individuals may receive a copy of their
addition, an ALE Member's EIN may not be truncated on the statement upon request. The notice must include an email
statements furnished to employees or the forms filed with the address, a physical address to which a request for a statement
IRS. may be sent, and a telephone number that individuals may use
to contact the employer with any questions. A notice posted on
Except as provided below, statements must be furnished on an employer’s website must be written in plain, non-technical
paper by mail (or hand delivered), unless the recipient terms and with letters of a font size large enough, including any
affirmatively consents to receive the statement in an electronic visual clues or graphical figures, to call to a viewer’s attention
format. If mailed, the statement must be sent to the employee's that the information pertains to tax statements reporting that
last known permanent address, or if no permanent address is individuals had health coverage. For example, an employer’s
known, to the employee's temporary address. For more website provides a clear and conspicuous notice if it (1) includes
information on furnishing statements to non-full-time employees a statement on the main page, or a link on the main page,
and non-employees who are enrolled in employer-sponsored reading “Tax Information,” to a secondary page that includes a
self-insured health coverage, see Alternative manner of statement, in capital letters, “IMPORTANT HEALTH COVERAGE
furnishing statements to non-full-time employees, later. TAX DOCUMENTS”; (2) explains how non-full-time employees
Consent to furnish statement electronically. An ALE and non-employees who are enrolled in the plan may request a
Member is required to obtain affirmative consent to furnish a copy of Form 1095-C; and (3) includes the employer’s email
statement electronically. This requirement ensures that address, mailing address, and telephone number.
statements are furnished electronically only to individuals who • The employer must post the notice on its website by March 1,
are able to access them. The consent must relate specifically to 2024, and retain the notice in the same location on its website
receiving the Form 1095-C electronically. An individual may through October 15, 2024.
consent on paper or electronically, such as by email. If consent is • The employer must furnish the statement to a requesting
on paper, the individual must confirm the consent electronically. individual within 30 days of the date the request is received. To

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satisfy this requirement, the employer may furnish the statement employer-level data for the ALE Member and be identified on
electronically if the recipient affirmatively consents. line 19 as the Authoritative Transmittal. If multiple Forms 1094-C
are being filed for an ALE Member so that Forms 1095-C for all
full-time employees of the ALE Member are not attached to a
Specific Instructions for Form 1094-C single Form 1094-C transmittal (because Forms 1095-C for
some full-time employees of the ALE Member are being
Part I—Applicable Large Employer Member transmitted separately), one (and only one) of the Forms 1094-C
(ALE Member) must report aggregate employer-level data for the ALE Member
and be identified on line 19 as the Authoritative Transmittal. For
Line 1. Enter employer's name. The employer is the ALE more information, see Authoritative Transmittal for ALE Members
Member. Filing Multiple Forms 1094-C, earlier.
Line 2. Enter the ALE Member’s EIN. Do not enter an SSN.
Enter the 9-digit EIN, including the dash. Part II—ALE Member Information
If you are filing Form 1094-C, a valid EIN is required at Reminder. Lines 20–22 should be completed only on the
! the time the form is filed. If a valid EIN is not provided, Authoritative Transmittal for the ALE Member. For more
CAUTION Form 1094-C will not be processed. If you do not have information, see Authoritative Transmittal for ALE Members Filing
an EIN, you may apply for one online. Go to IRS.gov/EIN. You Multiple Forms 1094-C, earlier.
may also apply by faxing or mailing Form SS-4, Application for
Line 20. Enter the total number of Forms 1095-C that will be
Employer Identification Number, to the IRS. See the Instructions
filed by, and/or on behalf of, the ALE Member. This includes all
for Form SS-4 and Pub. 1635, Employer Identification Number.
Forms 1095-C that are filed with this transmittal, including those
Lines 3–6. Enter the ALE Member’s complete address filed for individuals who enrolled in the employer-sponsored,
(including room or suite no., if applicable). This address should self-insured plan, if any, and for any Forms 1095-C filed with a
match the ALE Member’s address used on Form 1095-C. separate transmittal filed by, or on behalf of, the ALE Member.
Lines 7 and 8. Enter the name and telephone number of the Line 21. If during any month of the calendar year the ALE
person to contact who is responsible for answering any Member was a member of an Aggregated ALE Group, check
questions from the IRS regarding the filing of, or information “Yes.” If you check “Yes,” also complete the “Aggregated Group
reported on, Form 1094-C or 1095-C. This may be different than Indicator” in Part III, column (d), and then complete Part IV to list
the contact information on line 10 of Form 1095-C. the other members of the Aggregated ALE Group. If, for all 12
months of the calendar year, the employer was not a member of
Note. If you are a Designated Governmental Entity (DGE) filing an Aggregated ALE Group, check “No,” and do not complete
on behalf of an ALE Member, complete lines 9–16. If you are not Part III, column (d), or Part IV.
a DGE filing on behalf of an ALE Member, do not complete lines Line 22. If the ALE Member meets the eligibility requirements
9–16. Instead, skip to line 18. See Designated Governmental and is using one of the Offer Methods, it must check the
Entity (DGE) in the Definitions section of these instructions. applicable box. See the descriptions of Qualifying Offer Method
Line 9. If a DGE is filing on behalf of the ALE Member, enter the and 98% Offer Method, later.
name of the DGE. A. Qualifying Offer Method. Check this box if the ALE
Member is eligible to use, and is using, the Qualifying Offer
Line 10. Enter the DGE’s EIN (including the dash). Do not enter Method to report the information on Form 1095-C for one or
an SSN. more full-time employees. Under the Qualifying Offer Method,
If you are a DGE that is filing Form 1094-C, a valid EIN is there is an alternative method of completing Form 1095-C and
an alternative method for furnishing Form 1095-C to certain
CAUTION provided, the return will not be processed. If the DGE
! required at the time the return is filed. If a valid EIN is not employees. If the ALE Member is using either of these
does not have an EIN when filing Form 1094-C, it can get an EIN alternative rules, check this box. To be eligible to use the
by applying online at IRS.gov/EIN or by faxing or mailing a Qualifying Offer Method, the ALE Member must certify that it
completed Form SS-4. See the Instructions for Form SS-4 and made a Qualifying Offer to one or more of its full-time employees
Pub. 1635. for all months during the year in which the employee was a
full-time employee for whom an employer shared responsibility
Lines 11–14. Enter the DGE’s complete address (including payment could apply. Additional requirements described below
room or suite no.). must be met to be eligible to use the alternative method for
furnishing Form 1095-C to employees under the Qualifying Offer
Lines 15 and 16. Enter the name and telephone number of the Method.
person to contact who is responsible for answering any
questions from the IRS regarding the filing of, or information Alternative method of completing Form 1095-C under
reported on, Form 1094-C. the Qualifying Offer Method. If the ALE Member reports using
this method, it must not complete Form 1095-C, Part II, line 15,
Line 17. Reserved for future use. for any month for which a Qualifying Offer is made. Instead, it
Line 18. Enter the total number of Forms 1095-C submitted with must enter the Qualifying Offer code 1A on Form 1095-C,
this Form 1094-C transmittal. line 14, for any month for which the employee received a
Qualifying Offer (or in the “ All 12 Months” box if the employee
Line 19. If this Form 1094-C transmittal is the Authoritative received a Qualifying Offer for all 12 months), and must leave
Transmittal that reports aggregate employer-level data for the line 15 blank for any month for which code 1A is entered on
ALE Member, check the box on line 19 and complete Parts II, III, line 14. The ALE Member may, but is not required to, enter an
and IV, to the extent applicable. Otherwise, complete the applicable code on line 16 for any month for which code 1A is
signature portion of Form 1094-C and leave the remainder of entered on line 14; a Qualifying Offer is, by definition, treated as
Parts II, III, and IV blank. an offer that falls within an affordability safe harbor even if no
There must be only one Authoritative Transmittal filed for each code is entered on line 16.
ALE Member. If this is the only Form 1094-C being filed for the An ALE Member is not required to use the Qualifying Offer
ALE Member, this Form 1094-C must report aggregate Method even if it is eligible, and instead may enter on line 14 the

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applicable offer code and then enter on line 15 the Employee Non-Assessment Period, the ALE Member offered affordable
Required Contribution. health coverage providing minimum value to at least 98% of its
employees for whom it is filing a Form 1095-C employee
If the ALE Member is eligible to use the Qualifying Offer
statement, and offered minimum essential coverage to those
TIP Method, it may report on Form 1095-C by entering the
employees’ dependents. The ALE Member is not required to
Qualifying Offer code 1A on Form 1095-C, line 14, for
identify which of the employees for whom it is filing were full-time
any month for which it made a Qualifying Offer to an employee,
employees, but the ALE Member is still required, under the
even if the employee did not receive a Qualifying Offer for all 12
general reporting rules, to file Forms 1095-C on behalf of all its
calendar months. However, if an employee receives a Qualifying
full-time employees who were full-time employees for one or
Offer for less than all 12 months, the ALE Member must furnish a
more months of the calendar year. To ensure compliance with
copy of Form 1095-C to the employee (rather than using the
the general reporting rules, an ALE Member should confirm for
alternative method of furnishing Form 1095-C described later).
any employee for whom it fails to file a Form 1095-C that the
Example. Employee’s employment with Employer begins on employee was not a full-time employee for any month of the
January 1. Employee is in a health coverage waiting period (and calendar year. For this purpose, the health coverage is affordable
an employer shared responsibility payment could not apply with if the ALE Member meets one of the section 4980H affordability
respect to Employee, because Employee is in a Limited safe harbors.
Non-Assessment Period) until April 1 and is a full-time employee Example. Employer has 325 employees. Of those 325
for the remainder of the calendar year. Employer makes a employees, Employer identifies 25 employees as not possibly
Qualifying Offer to Employee for coverage beginning on April 1 being full-time employees because they are scheduled to work
and for the remainder of the calendar year. Employer is eligible 10 hours per week and are not eligible for additional hours. Of
to use the Qualifying Offer method because it has made a the remaining 300 employees, 295 are offered affordable
Qualifying Offer to at least one full-time employee for all months minimum value coverage for all periods during which they are
in which both (1) the employee was a full-time employee, and (2) employed other than any applicable waiting period (which
an employer shared responsibility payment could apply with qualifies as a Limited Non-Assessment Period). Employer files a
respect to the employee. Employer may use the alternative Form 1095-C for each of the 300 employees (excluding the 25
method of completing Form 1095-C under the Qualifying Offer employees that it identified as not possibly being full-time
Method for this Employee. However, Employer may not use the employees). Employer may use the 98% Offer Method because
alternative method of furnishing Form 1095-C to Employee under it makes an affordable offer of coverage that provides minimum
the Qualifying Offer Method because Employee did not receive a value to at least 98% of the employees for whom Employer files
Qualifying Offer for all 12 months of the calendar year. a Form 1095-C. Using this method, Employer does not identify
Alternative method of furnishing Form 1095-C to whether each of the 300 employees is a full-time employee.
employees under the Qualifying Offer Method. An ALE However, Employer must still file a Form 1095-C for all of its
Member that is eligible to use the Qualifying Offer Method may full-time employees. Employer chooses to file a Form 1095-C on
use the alternative method of furnishing Form 1095-C only for a behalf of all 300 employees, including the five employees to
full-time employee who (1) received a Qualifying Offer for all 12 whom it did not offer coverage, because if one or more of those
months of the calendar year, and (2) did not enroll in employees was, in fact, a full-time employee for one or more
employer-sponsored, self-insured coverage. For such an months of the calendar year, Employer would be required to
employee, an ALE Member meets its obligation to furnish a Form have filed a Form 1095-C on behalf of those employees.
1095-C to the employee if it furnishes the employee a statement
containing the following information. Note. If an ALE Member uses the 98% offer method, it is not
• Employer/ALE Member name, address, and EIN. required to complete the “Section 4980H Full-Time Employee
• Contact name and telephone number at which the employee Count for ALE Member” in Part III, column (b).
may receive information about the offer of coverage and the
information on the Form 1095-C filed with the IRS for that Part III—ALE Member Information—Monthly
employee. (Lines 23–35)
• Notification that, for all 12 months of the calendar year, the
employee and his or her spouse and dependents, if any, Column (a)—Minimum Essential Coverage Offer Indicator.
received a Qualifying Offer and therefore the employee is not • If the ALE Member offered minimum essential coverage,
eligible for a premium tax credit. including an individual coverage HRA, to at least 95% of its
• Information directing the employee to see Pub. 974, Premium full-time employees and their dependents for the entire calendar
Tax Credit (PTC), for more information on eligibility for the year, enter “X” in the “Yes” checkbox on line 23 for “All 12
premium tax credit. Months” or for each of the 12 calendar months.
An ALE Member is not required to use the alternative method • If the ALE Member offered minimum essential coverage,
of furnishing for an employee even if the alternative method including an individual coverage HRA, to at least 95% of its
would be allowed. Instead, the ALE Member may furnish a copy full-time employees and their dependents only for certain
of Form 1095-C as filed with the IRS (with or without the calendar months, enter “X” in the “Yes” checkbox for each
statement described earlier). applicable month.
• For the months, if any, for which the ALE Member did not offer
As stated earlier, an ALE Member may not use the alternative minimum essential coverage, including an individual coverage
furnishing method for a full-time employee who enrolled in HRA, to at least 95% of its full-time employees and their
self-insured coverage. Rather, the ALE Member must furnish dependents, enter “X” in the “No” checkbox for each applicable
Form 1095-C, including the information reporting enrollment in month.
the coverage on Form 1095-C, Part III. • If the ALE Member did not offer minimum essential coverage,
B. Reserved for future use. including an individual coverage HRA, to at least 95% of its
C. Reserved for future use. full-time employees and their dependents for any of the 12
D. 98% Offer Method. Check this box if the employer is months, enter “X” in the “No” checkbox for “All 12 Months” or for
eligible for, and is using, the 98% Offer Method. To be eligible to each of the 12 calendar months.
use the 98% Offer Method, an employer must certify that, taking
into account all months during which the individuals were Note. For purposes of column (a), an employee in a Limited
employees of the ALE Member and were not in a Limited Non-Assessment Period is not counted in determining whether

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minimum essential coverage was offered to at least 95% of an employees in a Limited Non-Assessment Period, for each
ALE Member’s full-time employees and their dependents. For a calendar month. An ALE Member must choose to use one of the
description of the differences between the definition of the term following days of the month to determine the number of
“Limited Non-Assessment Period” used with respect to section employees per month and must use that day for all months of the
4980H(a) and the definition used with respect to section year: (1) the first day of each month, (2) the last day of each
4980H(b), relating to whether the ALE Member offers minimum month, (3) the 12th day of each month, (4) the first day of the first
value coverage at the end of the Limited Non-Assessment payroll period that starts during each month, or (5) the last day of
Period, see the Definitions section. the first payroll period that starts during each month (provided
that for each month that last day falls within the calendar month
An employee who is treated as having been offered
in which the payroll period starts). If the total number of
TIP health coverage, including an individual coverage HRA,
employees was the same for every month of the entire calendar
for purposes of section 4980H (even though not actually
year, enter that number in line 23, column (c), “All 12 Months,” or
offered) is treated as offered minimum essential coverage for this
in the boxes for each month of the calendar year. If the number
purpose. For example, for the months for which the ALE Member
of employees for any month is zero, enter -0-.
is eligible for multiemployer arrangement interim guidance (if the
ALE Member is contributing on behalf of an employee whether Column (d)—Aggregated Group Indicator. An ALE Member
or not the employee is eligible for coverage under the must complete this column if it checked “Yes” on line 21,
multiemployer plan) with respect to an employee, that employee indicating that, during any month of the calendar year, it was a
should be treated as having been offered minimum essential member of an Aggregated ALE Group. If the ALE Member was a
coverage for purposes of column (a). For different rules for member of an Aggregated ALE Group during each month of the
purposes of reporting offers of coverage on Form 1095-C, see calendar year, enter “X” in the “All 12 Months” box or in the boxes
the specific instructions for Form 1095-C, Part II, line 14. for each of the 12 calendar months. If the ALE Member was not
a member of an Aggregated ALE Group for all 12 months but
For purposes of column (a), if the ALE Member offered was a member of an Aggregated ALE Group for one or more
TIP minimum essential coverage to all but five of its full-time month(s), enter “X” in each month for which it was a member of
employees and their dependents, and five is greater an Aggregated ALE Group. If an ALE Member enters “X” in one
than 5% of the number of full-time employees of the ALE or more months in this column, it must also complete Part IV.
Member, the ALE Member may report in column (a) as if it
offered health coverage to at least 95% of its full-time employees Part IV—Other ALE Members of
and their dependents (even if it offered health coverage to less Aggregated ALE Group (Lines 36–65)
than 95% of its full-time employees and their dependents, for
example, to 75 of its 80 full-time employees and their An ALE Member must complete this section if it checks “Yes” on
dependents). line 21. If the ALE Member was a member of an Aggregated ALE
Group (with other ALE Members) for any month of the calendar
See Definitions, later, for more information on an offer of year, enter the name(s) and EIN(s) of up to 30 of the other
health coverage. Aggregated ALE Group members (not including the reporting
ALE Member). If there are more than 30 members of the
Column (b)—Section 4980H Full-Time Employee Count for Aggregated ALE Group (not including the reporting ALE
ALE Member. Enter the number of full-time employees for each Member), enter the 30 with the highest monthly average number
month, but do not count any employee in a Limited of full-time employees (using the number reported in Part III,
Non-Assessment Period. If the number of full-time employees column (b), if a number was required to be reported) for the year
(excluding employees in a Limited Non-Assessment Period) for a or for the number of months during which the ALE Member was
month is zero, enter -0-. An employee should be counted as a a member of the Aggregated ALE Group. If any member of the
full-time employee for a month if the employee satisfied the Aggregated ALE Group uses the 98% Offer Method and thus is
definition of “full-time employee” under the monthly not required to identify which employees are full-time employees,
measurement method or the look-back measurement method all ALE Members of the Aggregated ALE Group should use the
(as applicable) on any day of the month. See Full-time employee monthly average number of total employees rather than the
and Limited Non-Assessment Period in the Definitions section. monthly average number of full-time employees for this purpose.
Be sure to use the section 4980H definition and not any other Regardless of the number of members in the Aggregated ALE
definition of the term “full-time employee” that you may use for Group, list only the 30 members in descending order, listing first
other purposes. the member with the highest average monthly number of full-time
Example. Employer uses the look-back measurement employees (or highest average number of total employees, if any
method to determine the full-time status of its employees. member of the Aggregated ALE Group uses the 98% Offer
Employee, who is not in a Limited Non-Assessment Period, Method), but do not include the reporting ALE Member. The
averaged over 130 hours of service per month during the reporting ALE Member must also complete Part III, column (d),
measurement period that corresponds with the stability period to indicate which months it was part of an Aggregated ALE
starting January 1, 2023, and ending December 31, 2023. Group.
Employee terminates employment with Employer on February If you are filing Form 1094-C, a valid EIN is required at
15, 2023. Employer must include Employee in the number of ! the time it is filed. If a valid EIN is not provided, Form
full-time employees reported in column (b) for January and CAUTION 1094-C will not be processed. If you do not have an EIN,
February. See the description of code 2B in the instructions for you may apply for one online. Go to IRS.gov/EIN. You may also
line 16 of Form 1095-C, later, for rules for reporting an offer of apply by faxing or mailing Form SS-4 to the IRS. See the
coverage in an employee’s final month of employment. Instructions for Form SS-4 and Pub. 1635.
Note. If the ALE Member certified that it was eligible for the 98%
Offer Method by selecting box D, on line 22, it is not required to
complete column (b).
Column (c)—Total Employee Count for ALE Member. Enter
the total number of all of the ALE Member’s employees,
including full-time employees and non-full-time employees, and

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plan), the employee does not actually have an offer of coverage
Specific Instructions for Form 1095-C for that month (and code 1H should therefore be entered on
line 14). See line 16, code 2B, later, for how the ALE Member
Part I—Employee may complete line 16 in the event that coverage terminates
before the last day of the month.
Line 1. Enter the name of the employee (first name, middle A code must be entered for each calendar month, January
initial, last name). through December, even if the employee was not a full-time
Line 2. Enter the 9-digit SSN of the employee (including the employee for one or more of the calendar months. Enter the
dashes). code identifying the type of health coverage actually offered by
the ALE Member (or on behalf of the ALE Member) to the
Lines 3–6. Enter the employee’s complete address, including employee, if any. If the employee was not actually offered
apartment no., if applicable. A country code is not required for coverage, enter code 1H (no offer of coverage) on line 14.
U.S. addresses.
For reporting offers of coverage for 2023, an ALE Member
Part I—Applicable Large Employer Member relying on the multiemployer arrangement interim guidance
should enter code 1H on line 14 for any month for which the ALE
(Employer) Member enters code 2E on line 16 (indicating that the ALE
Line 7. Enter the name of the ALE Member. Member was required to contribute to a multiemployer plan on
behalf of the employee for that month and therefore is eligible for
Line 8. Enter the ALE Member’s EIN. Do not enter an SSN. multiemployer interim rule relief). For a description of the
Enter the 9-digit EIN, including the dash. The ALE Member’s multiemployer arrangement interim guidance, see Offer of health
name and EIN should match the name and EIN of the ALE coverage in the Definitions section. For reporting for 2023, code
Member reported on lines 1 and 2 of Form 1094-C. 1H may be entered without regard to whether the employee was
If you are filing Form 1095-C, a valid EIN is required at eligible to enroll, or enrolled in, coverage under the
multiemployer plan. For reporting for 2024 and future years, ALE
CAUTION 1095-C will not be processed. If you do not have an EIN,
! the time it is filed. If a valid EIN is not provided, Form Members relying on the multiemployer arrangement interim
you may apply for one online. Go to IRS.gov/EIN. You may also guidance may be required to report offers of coverage made
apply by faxing or mailing Form SS-4 to the IRS. See the through a multiemployer plan in a different manner.
Instructions for Form SS-4 and Pub. 1635.
Indicator Codes for Employee Offer of Coverage
Lines 9 and 11–13. Enter the ALE Member’s complete address
(including room or suite no., if applicable). This address should (Form 1095-C, Line 14)
match the address reported on lines 3–6 of the Form 1094-C. Code Series 1—Offer of Coverage. The Code Series 1
Line 10. Enter the telephone number of the person to contact indicator codes specify the type of coverage, if any, offered to an
whom the recipient may call about the information reported on employee, the employee’s spouse, and the employee’s
the form. This may be different than the contact information dependents. The term Dependent has the specific meaning set
entered on line 8 of Form 1094-C. forth in the Definitions section of these instructions. In addition,
for this purpose, an offer of coverage is treated as made to an
Part II—Employee Offer of Coverage employee’s dependents only if the offer of coverage is made to
an unlimited number of dependents regardless of the actual
Age. If the employee was offered an individual coverage HRA, number of dependents, if any, an employee has during any
enter the employee’s age on January 1, 2023. Note that for particular calendar month.
non-calendar year plans or for employees who become eligible
during the plan year, this age may not be the Applicable age If the type of coverage, if any, offered to an employee was the
used to determine Employee Required Contribution. same for all 12 months in the calendar year, enter the Code
Series 1 indicator code corresponding to the type of coverage
Plan Start Month. This box is required for the 2023 Form offered either in the “All 12 Months” box or in each of the 12
1095-C and the ALE Member may not leave it blank. To boxes for the calendar months.
complete the box, enter the 2-digit number (01 through 12) Conditional offer of spousal coverage. Codes 1J and 1K
indicating the calendar month during which the plan year begins address conditional offers of spousal coverage (also referred to
of the health plan in which the employee is offered coverage (or as “coverage offered conditionally”). A conditional offer is an
would be offered coverage if the employee were eligible to offer of coverage that is subject to one or more reasonable,
participate in the plan). If more than one plan year could apply objective conditions (for example, an offer to cover an
(for instance, if the ALE Member changes the plan year during employee’s spouse only if the spouse is not eligible for coverage
the year), enter the earliest applicable month. If there is no health under Medicare or a group health plan sponsored by another
plan under which coverage is offered to the employee, enter “00.” employer). Using codes 1J and 1K, an ALE Member may report
Line 14. For each calendar month, enter the applicable code a conditional offer to a spouse as an offer of coverage,
from Code Series 1. If the same code applies for all 12 calendar regardless of whether the spouse meets the reasonable,
months, you may enter the applicable code in the “All 12 Months” objective condition. A conditional offer may impact a spouse's
box and not complete the individual calendar month boxes, or eligibility for the premium tax credit under section 36B only if all
you may enter the code in each of the boxes for the 12 calendar conditions to the offer are satisfied (that is, the spouse was
months. If an employee was not offered coverage for a month, actually offered the coverage and eligible for it) and the
enter code 1H. Do not leave line 14 blank for any month Exchange makes a determination about the affordability of the
(including months when the individual was not an employee of offer. To help employees (and spouses) who have received a
the ALE Member). An ALE Member offers health coverage for a conditional offer determine their eligibility for the premium tax
month only if it offers health coverage that would provide credit, the ALE Member should be prepared to provide, upon
coverage for every day of that calendar month. Thus, if coverage request, a list of any and all conditions applicable to the spousal
terminates before the last day of the month (because, for offer of coverage. As is noted in the definition of Dependent in
instance, the employee terminates employment with the ALE the Definitions section, a spouse is not a dependent for
Member, or otherwise loses eligibility for coverage under the purposes of section 4980H.

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An ALE Member may not report a conditional offer of offer of coverage on line 14. If the ALE Member is otherwise
coverage to an employee’s dependents as an offer to the required to file Form 1095-C for the former employee (because,
dependents, unless the ALE Member knows that the for example, the individual was a full-time employee for one or
dependents met the condition to be eligible for the ALE more months in the calendar year in which the termination of
Member’s coverage. Further, an offer of coverage is treated as employment occurred), the ALE Member should enter code 1H
made to an employee’s dependents only if the offer of coverage (no offer of coverage) on line 14 for any month to which an offer
is made to an unlimited number of dependents regardless of the of post-employment coverage applies, and should also enter
actual number of dependents, if any, an employee has during code 2A (not an employee) on line 16 (see the instructions for
any particular calendar month. line 16).
COBRA continuation coverage. An offer of COBRA For additional information, including examples about
continuation coverage is reported differently depending on TIP reporting offers of COBRA continuation coverage and
whether or not the offer is made due to an employee’s post-employment coverage, go to IRS.gov/Affordable-
termination of employment. Care-Act/Employers/Questions-and-Answers-about-Information-
An offer of COBRA continuation coverage that is made to a Reporting-by-Employers-on-Form-1094-C-and-Form-1095-C.
former employee (or to a former employee’s spouse or
dependents) due to termination of employment should not be • 1A. Qualifying Offer: Minimum essential coverage providing
reported as an offer of coverage on line 14. In this situation, code minimum value offered to full-time employee with Employee
1H (No offer of coverage) must be entered on line 14 for any Required Contribution equal to or less than 9.5% (as adjusted) of
month for which the offer of COBRA continuation coverage mainland single federal poverty line and at least minimum
applies, and code 2A (Employee not employed during the essential coverage offered to spouse and dependent(s).
month) must be entered on line 16 (see the instructions for This code may be used to report for specific months for
line 16), without regard to whether the employee or spouse or TIP which a Qualifying Offer was made, even if the employee
dependents enrolled in the COBRA coverage. However, for the did not receive a Qualifying Offer for all 12 months of the
month in which the employee terminates employment with the calendar year. However, an ALE Member may not use the
ALE Member, see the instructions for line 16, code 2B. Alternative Furnishing Method for an employee who did not
An offer of COBRA continuation coverage that is made to an receive a Qualifying Offer for all 12 calendar months.
employee who remains employed by the ALE Member (or to that 1B. Minimum essential coverage providing minimum value
employee’s spouse and dependents) should be reported on •
offered to employee only.
line 14 as an offer of coverage, but only for any individual who 1C. Minimum essential coverage providing minimum value
receives an offer of COBRA continuation coverage (or an offer of •
offered to employee and at least minimum essential coverage
similar coverage that is made at the same time as the offer of offered to dependent(s) (not spouse).
COBRA continuation coverage is made to enrolled individuals). 1D. Minimum essential coverage providing minimum value
Generally, an offer of COBRA continuation coverage is required •
offered to employee and at least minimum essential coverage
to be made only to individuals who were enrolled in coverage offered to spouse (not dependent(s)). Do not use code 1D if the
and would lose eligibility for coverage due to the COBRA coverage for the spouse was offered conditionally. Instead, use
qualifying event, but an ALE Member may choose to extend a code 1J.
similar offer of coverage to a spouse or dependent even if the 1E. Minimum essential coverage providing minimum value
offer is not required by COBRA. •
offered to employee and at least minimum essential coverage
Example. During the applicable open enrollment period for offered to dependent(s) and spouse. Do not use code 1E if the
its health plan, Employer makes an offer of minimum essential coverage for the spouse was offered conditionally. Instead, use
coverage providing minimum value to Employee and to code 1K.
Employee’s spouse and dependents. Employee elects to enroll • 1F. Minimum essential coverage NOT providing minimum
in employee-only coverage starting January 1. On June 1, value offered to employee; employee and spouse or
Employee experiences a reduction in hours that results in loss of dependent(s); or employee, spouse, and dependents.
eligibility for coverage under the plan. As of June 1, Employer • 1G. Offer of coverage for at least one month of the calendar
terminates Employee’s existing coverage and makes an offer of year to an individual who was not an employee for any month of
COBRA continuation coverage to Employee, but does not make the calendar year or to an employee who was not a full-time
an offer to Employee’s spouse and dependents. Employer employee for any month of the calendar year (which may include
should enter code 1E (Minimum essential coverage providing one or more months in which the individual was not an
minimum value offered to employee and at least minimum employee) and who enrolled in self-insured coverage for one or
essential coverage offered to dependent(s) and spouse) on more months of the calendar year.
line 14 for months January–May, and should enter code 1B
(Minimum essential coverage providing minimum value offered Note. Code 1G applies for the entire year or not at all.
to employee only) on line 14 for months June–December. Therefore, if code 1G applies, an ALE Member must enter code
1G on line 14 in the “All 12 Months” column or in each separate
Note. Notwithstanding the preceding instructions for completing monthly box (for all 12 months).
line 14 of Form 1095-C, for purposes of section 4980H, an ALE • 1H. No offer of coverage (employee not offered any health
Member is treated as having made an offer to the employee’s coverage or employee offered coverage that is not minimum
dependents for an entire plan year if the ALE Member provided essential coverage, which may include one or more months in
the employee an effective opportunity to enroll the employee’s which the individual was not an employee).
dependents at least once for the plan year, even if the employee • 1I. Reserved for future use.
declined to enroll the dependents in the coverage and, as a • 1J. Minimum essential coverage providing minimum value
result, the dependents later did not receive an offer of COBRA offered to employee and at least minimum essential coverage
coverage. conditionally offered to spouse; minimum essential coverage not
Post-employment (non-COBRA) coverage. An offer of offered to dependent(s). (See Conditional offer of spousal
post-employment coverage to a former employee (or to that coverage, earlier, for an additional description of conditional
former employee’s spouse or dependent(s)) for coverage that offers.)
would be effective after the employee has terminated • 1K. Minimum essential coverage providing minimum value
employment (such as at retirement) should not be reported as an offered to employee; at least minimum essential coverage

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offered to dependents; and at least minimum essential coverage Line 16. For each calendar month, enter the applicable code, if
conditionally offered to spouse. (See Conditional offer of spousal any, from Code Series 2. Enter only one code from Code Series
coverage, earlier, for an additional description of conditional 2 per calendar month. The instructions below address which
offers.) code to use for a month if more than one code from Code Series
• 1L. Individual coverage HRA offered to employee only with 2 could apply. If the same code applies for all 12 calendar
affordability determined by using employee’s primary residence months, you may enter the code in the “All 12 Months” box and
location ZIP code. not complete the monthly boxes. If none of the codes apply for a
• 1M. Individual coverage HRA offered to employee and calendar month, leave the line blank for that month.
dependent(s) (not spouse) with affordability determined by using
employee’s primary residence location ZIP code. Code Series 2—Section 4980H Safe Harbor Codes and
• 1N. Individual coverage HRA offered to employee, spouse, Other Relief for ALE Members. An ALE Member enters the
and dependent(s) with affordability determined by using applicable Code Series 2 indicator code, if any, on line 16 to
employee’s primary residence location ZIP code. report for one or more months of the calendar year that one of
• 1O. Individual coverage HRA offered to employees only using the following situations applied to the employee.
the employee’s primary employment site ZIP code affordability • The employee was not employed or was not a full-time
safe harbor. employee,
• 1P. Individual coverage HRA offered to employee and • The employee enrolled in the minimum essential coverage
dependent(s) (not spouse) using the employee’s primary offered,
employment site ZIP code affordability safe harbor. • The employee was in a Limited Non-Assessment Period with
• 1Q. Individual coverage HRA offered to employee, spouse, respect to section 4980H(b),
and dependent(s) using employee’s primary employment site • The ALE Member met one of the section 4980H affordability
ZIP code affordability safe harbor. safe harbors with respect to this employee, or
• 1R. Individual coverage HRA that is NOT affordable offered to • The ALE Member was eligible for multiemployer interim rule
employee; employee and spouse, or dependent(s); or employee, relief for this employee.
spouse, and dependents. If no indicator code applies, leave line 16 blank. In some
• 1S. Individual coverage HRA offered to an individual who was circumstances, more than one indicator code could apply to the
not a full-time employee. same employee in the same month. For example, an employee
• 1T. Individual coverage HRA offered to employee and spouse could be enrolled in health coverage for a particular month
(not dependents) with affordability determined using employee's during which he or she is not a full-time employee. However, only
primary residence location ZIP code. one code may be used for a particular calendar month. For any
• 1U. Individual coverage HRA offered to employee and spouse month in which an employee enrolled in minimum essential
(not dependents) using employee's primary employment site ZIP coverage, in general, indicator code 2C reporting enrollment is
code affordability safe harbor. used instead of any other indicator code that could also apply
• 1V. Reserved for future use. (but see the exceptions to this rule below regarding the
• 1W. Reserved for future use. multiemployer interim rule relief and enrollment in COBRA
• 1X. Reserved for future use. continuation coverage or other post-employment coverage). For
• 1Y. Reserved for future use. an employee who did not enroll in health coverage, there are
• 1Z. Reserved for future use. some specific ordering rules for which code to use. See the
descriptions of the codes.
Line 15. Complete line 15 only if code 1B, 1C, 1D, 1E, 1J, 1K,
1L, 1M, 1N, 1O, 1P, 1Q, 1T, or 1U is entered on line 14 either in Note. There is no code to enter on line 16 to indicate that a
the “All 12 Months” box or in any of the monthly boxes. Enter the full-time employee offered coverage either did not enroll in the
amount of the Employee Required Contribution, which is, coverage or waived the coverage.
generally, the employee share of the monthly cost for the 2A. Employee not employed during the month. Enter code 2A
lowest-cost, self-only, minimum essential coverage providing •
if the employee was not employed on any day of the calendar
minimum value that is offered to the employee. For additional month. Do not use code 2A for a month if the individual was an
details on how to determine the Employee Required employee of the ALE Member on any day of the calendar month.
Contribution, including how to determine the Employee Required Do not use code 2A for the month during which an employee
Contribution for the individual coverage HRA, see the Definitions terminates employment with the ALE Member.
section, later. Enter the amount, including any cents. If the 2B. Employee not a full-time employee. Enter code 2B if the
employee is offered coverage but the Employee Required •
employee is not a full-time employee for the month and did not
Contribution is zero, enter “0.00” (do not leave blank). If the enroll in minimum essential coverage, if offered for the month.
Employee Required Contribution was the same amount for all 12 Enter code 2B also if the employee is a full-time employee for the
calendar months, you may enter that monthly amount in the “All month and whose offer of coverage (or coverage if the employee
12 Months” box and not complete the monthly boxes. If the was enrolled) ended before the last day of the month solely
Employee Required Contribution was not the same for all 12 because the employee terminated employment during the month
months (for instance, if an ALE Member has a noncalendar year (so that the offer of coverage or coverage would have continued
plan and the employee share of the premium changes with the if the employee had not terminated employment during the
new plan year that starts in 2023), enter the amount in each month).
calendar month for which the employee was offered minimum 2C. Employee enrolled in health coverage offered. Enter code
value coverage. See the definition of Employee Required •
2C for any month in which the employee enrolled for each day of
Contribution in the Definitions section, for more information, the month in health coverage offered by the ALE Member,
including on how to determine the monthly required contribution regardless of whether any other code in Code Series 2 might
from annual data. also apply (for example, the code for a section 4980H
For line 15, the amount entered might not be the amount affordability safe harbor) except as provided below. Do not enter
TIP the employee is paying for the coverage, for example, if code 2C on line 16 for any month in which the multiemployer
the employee chose to enroll in more expensive interim rule relief applies (enter code 2E). Do not enter code 2C
coverage, such as family coverage, or if the employee is eligible on line 16 if code 1G is entered on line 14. Do not enter code 2C
for certain other healthcare arrangements. on line 16 for any month in which a terminated employee is
enrolled in COBRA continuation coverage or other

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post-employment coverage (enter code 2A). Do not enter code of the employee’s primary site of employment if the ALE Member
2C on line 16 for any month in which the employee enrolled in uses the work location safe harbor (code 1O, 1P, 1Q, or 1U).
coverage that was not minimum essential coverage.
Location safe harbor for individual coverage HRAs. For
• 2D. Employee in a section 4980H(b) Limited Non-Assessment
purposes of section 4980H(b), an employer may use the cost of
Period. Enter code 2D for any month during which an employee
self-only coverage for the lowest cost silver plan for the
is in a section 4980H(b) Limited Non-Assessment Period. If an
employee for self-only coverage offered through the Exchange
employee is in an initial measurement period, enter code 2D
where the employee’s primary site of employment is located for
(employee in a section 4980H(b) Limited Non-Assessment
determining whether an offer of an individual coverage HRA to a
Period) for the month, and not code 2B (employee not a full-time
full-time employee is affordable. The ZIP code for the employee’s
employee). For an employee in a section 4980H(b) Limited
primary site of employment is used to identify the applicable
Non-Assessment Period for whom the ALE Member is also
lowest cost silver plan to determine affordability.
eligible for the multiemployer interim rule relief for the month,
enter code 2E (multiemployer interim rule relief) and not code 2D
Part III—Covered Individuals (Lines 18–30)
(employee in a section 4980H(b) Limited Non-Assessment
Period). Note. If there are more than 13 covered individuals, additional
• 2E. Multiemployer interim rule relief. Enter code 2E for any copies of page 3, Part III, may be used.
month for which the multiemployer arrangement interim Complete Part III ONLY if the ALE Member offers
guidance applies for that employee, regardless of whether any employer-sponsored, self-insured health coverage, including an
other code in Code Series 2 (including code 2C) might also individual coverage HRA, in which the employee or other
apply. This relief is described under Offer of Health Coverage in individual enrolled. For this purpose, employer-sponsored,
the Definitions section of these instructions. self-insured health coverage does not include coverage under a
Note. Although ALE Members may use the section 4980H multiemployer plan. Do not complete Part III if the ALE Member
affordability safe harbors to determine affordability for purposes offers coverage only under an insured group health plan. If an
of the multiemployer arrangement interim guidance, an ALE ALE Member offers both insured and self-insured coverage,
Member eligible for the relief provided in the multiemployer complete Part III only for employees who enroll in the
arrangement interim guidance for a month for an employee self-insured coverage.
should enter code 2E (multiemployer interim rule relief), and not An ALE Member with a self-insured major medical plan and a
code 2F, 2G, or 2H (codes for section 4980H affordability safe health reimbursement arrangement (HRA) that has an individual
harbors). who enrolls in both types of minimum essential coverage is
• 2F. Section 4980H affordability Form W-2 safe harbor. Enter required to report the individual’s coverage under only one of the
code 2F if the ALE Member used the section 4980H Form W-2 arrangements in Part III. An ALE Member with an insured major
safe harbor to determine affordability for purposes of section medical plan and an HRA that has an individual who enrolls in
4980H(b) for this employee for the year. If an ALE Member uses both types of minimum essential coverage is not required to
this safe harbor for an employee, it must be used for all months report in Part III the HRA coverage of an individual if the
of the calendar year for which the employee is offered health individual is eligible for the HRA because the individual enrolled
coverage. in the insured major medical plan. An ALE Member with an HRA
• 2G. Section 4980H affordability federal poverty line safe must report coverage under the HRA in Part III for any individual
harbor. Enter code 2G if the ALE Member used the section who is not enrolled in a major medical plan of the ALE Member
4980H federal poverty line safe harbor to determine affordability (for example, if the individual is enrolled in a group health plan of
for purposes of section 4980H(b) for this employee for any another employer (such as spousal coverage) or if the ALE
month(s). Member provides an individual coverage HRA). For additional
• 2H. Section 4980H affordability rate of pay safe harbor. Enter information on the reporting of supplemental coverage, see
code 2H if the ALE Member used the section 4980H rate of pay Proposed Regulations section 1.6055-1(d)(2) and (3).
safe harbor to determine affordability for purposes of section
4980H(b) for this employee for any month(s). If the ALE Member is completing Part III, enter “X” in the
checkbox in Part III. If the ALE Member is not completing Part III,
Note. An affordability safe harbor code should not be entered do not enter “X” in the checkbox in Part III.
on line 16 for any month that the ALE Member did not offer
minimum essential coverage, including an individual coverage This part must be completed by an ALE Member offering
HRA, to at least 95% of its full-time employees and their self-insured health coverage for any individual who was an
dependents (that is, any month for which the ALE Member employee for one or more calendar months of the year, whether
checked the “No” box on Form 1094-C, Part III, column (a)). For full-time or non-full-time, and who enrolled in the coverage. The
more information, see the instructions for Form 1094-C, Part III, employee (if enrolled in self-insured coverage) should be listed
column (a). on line 18; any other family members who enrolled in coverage
• 2I. Reserved for future use. offered to the employee should be listed on subsequent lines.
All employee family members that are covered
Note. References to 9.5% in the section 4980H affordability TIP individuals through the employee’s enrollment (for
safe harbors and Qualifying Offer Method are applied based on example, because the employee elected family
the percentage as indexed for purposes of applying the coverage) must be included on the same form as the employee
affordability thresholds under section 36B (the premium tax (or any other individual to whom the offer was made). For
credit). The percentage, as adjusted, is 9.61% for plan years example, if the employee is offered family coverage by his or her
beginning in 2022, and 9.12% for plan years beginning in 2023. employer under a self-insured health plan and enrolls in the
Line 17. If the ALE Member used code 1L, 1M, 1N, 1O, 1P, 1Q, family coverage, the employee and the employee’s family
1T, or 1U because it offered the employee an individual coverage members that are covered under the plan must all be reported
HRA, enter the appropriate ZIP code used for identifying the on the same Form 1095-C.
lowest cost silver plan used to calculate the Employee Required
Contribution in line 15. This will be the ZIP code of the If two or more employees employed by the same ALE
employee’s residence (code 1L, 1M, 1N, or 1T) or the ZIP code Member are spouses or an employee and his or her dependent,
and one employee enrolled in a coverage option under the plan
that also covered the other employee(s) (for example, one
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employee spouse enrolled in family coverage that provided employee listed in Part I, a taxpayer identification number (TIN),
coverage to the other employee spouse and their employee rather than an SSN, may be entered if the covered individual
dependent child), the enrollment information should be reflected does not have an SSN, or the field may be left blank if the
only on Form 1095-C for the employee who enrolled in the covered individual does not have a TIN.
coverage. (However, it would report the other employee family
Column (c). Enter a date of birth (YYYY-MM-DD) for the
members as covered individuals.)
covered individual only if column (b) is blank.
Coverage of non-employee. This part may be completed by
Column (d). Check this box if the individual was covered for at
an ALE Member offering self-insured health coverage for any
least one day per month for all 12 months of the calendar year.
other individual who enrolled in the coverage under the plan for 1
or more calendar months of the year but was not an employee Column (e). If the individual was not covered for all 12 months
for any calendar month of the year, such as a non-employee of the calendar year, check the applicable box(es) for the
director, a retired employee who retired in a previous year, a month(s) in which the individual was covered for at least 1 day in
terminated employee receiving COBRA continuation coverage the month.
(or any other form of post-employment coverage) who
terminated employment during a previous year, and a
non-employee COBRA beneficiary (but not including an Definitions
individual who obtained coverage through the employee’s This section contains the definitions of key terms used in Forms
enrollment, such as a spouse or dependent obtaining coverage 1094-C and 1095-C and these instructions. For definitions of
when an employee elects COBRA continuation coverage that is terms not included in this section, see the final regulations under
family coverage). If Form 1095-C is used with respect to an section 4980H, T.D. 9655, 2014-9 I.R.B. 541, at IRS.gov/irb/
individual who was not an employee for any month of the 2014-9_IRB/ar05.html and section 6056, T.D. 9661, 2014-13
calendar year, Part II must be completed by using code 1G in the I.R.B. 855, at IRS.gov/irb/2014-13_IRB/ar09.html.
“All 12 Months” box or the separate monthly boxes for all 12 Affordability. Generally, the lowest cost silver plan for the
calendar months. The employer must report for these individuals employee based on the employee’s residence is used to
using Form 1095-B, if it chooses not to use Form 1095-C. determine affordability. The ZIP code for the employee’s
If a non-employee individual enrolls in the coverage residence is used to identify the applicable lowest cost silver
TIP under a self-insured health plan, all family members that plan to determine affordability.
are covered individuals because of the individual’s Aggregated ALE Group. An Aggregated ALE Group refers to a
enrollment must be included on the same Form 1095-B or Form group of ALE Members treated as a single employer under
1095-C as the individual who is offered, and enrolls in, the section 414(b), 414(c), 414(m), or 414(o). An ALE Member is a
coverage. member of an Aggregated ALE Group for a month if it is treated
as a single employer with the other members of the group on any
Columns (a) through (e), as applicable, must be completed day of the calendar month. If an ALE is made up of only one
for each individual enrolled in the coverage, including the person or entity, that one ALE Member is not a part of an
employee reported on line 1. Enter the 9-digit SSN or other TIN Aggregated ALE Group. Government entities and churches or
for each covered individual in column (b). Enter a date of birth in conventions or associations of churches may apply a
column (c) only if an SSN or other TIN is not entered in column reasonable, good faith interpretation of the aggregation rules
(b). Column (d) will be checked if the individual was covered for under section 414 in determining their status as an ALE or
at least 1 day in every month of the year. For individuals who member of an Aggregated ALE Group. For more information on
were covered for some but not all months, information will be how the aggregation rules apply to government entity employers,
entered in column (e) indicating the months for which these see Notice 2015-87, Q&A 18, at IRS.gov/irb/2015-52_IRB/
individuals were covered. ar11.html.
Governmental Unit employers offering self-insured Applicable Large Employer (ALE). An ALE is, for a particular
TIP health coverage that have delegated another calendar year, any single employer, or group of employers
Governmental Unit (DGE) for purposes of reporting and treated as an Aggregated ALE Group, that employed an average
furnishing enrollment information (meaning the information that of at least 50 full-time employees (including full-time equivalent
otherwise would be reported on Form 1095-C, Part III), but have employees) on business days during the preceding calendar
not designated a DGE for purposes of reporting and furnishing year. For purposes of determining an employer’s average
offer of coverage information (meaning the information that is number of employees, disregard an employee for any month in
reported on Form 1095-C, Part II), should file and furnish Forms which the employee has coverage under a plan described in
1095-C with a completed Part I and Part II, but not a completed section 4980H(c)(2)(F) (generally, TRICARE or Veterans
Part III, and should not check the box indicating that the Administration coverage). A new employer (that is, an employer
Governmental Unit offers self-insured health coverage. In this that was not in existence on any business day in the prior
case, the DGE should file Forms 1094-B and 1095-B to report calendar year) is an ALE for the current calendar year if it
enrollment information for employees on behalf of the reasonably expects to employ, and actually does employ, an
Governmental Unit. See FAQs on IRS.gov. average of at least 50 full-time employees (including full-time
A DGE that has been delegated by a Governmental Unit for equivalent employees) on business days during the current
purposes of reporting and furnishing both offer of coverage and calendar year. For information on a special rule for certain
enrollment information (meaning the information that would be employers with seasonal workers, see the final regulations under
reported on Parts II and III of Form 1095-C) should file Forms section 4980H and FAQs on IRS.gov.
1094-C and 1095-C to report the information for employees on Applicable Large Employer Member (ALE Member). An
behalf of the Governmental Unit. ALE Member is a single person or entity that is an ALE, or if
Column (a). Enter the name of each covered individual (first applicable, each person or entity that is a member of an
name, middle initial, last name), including the employee, if the Aggregated ALE Group. A person or entity that does not have
employee is enrolled in self-insured coverage. employees or only has employees with no hours of service (for
example, only employees whose entire service consists of work
Column (b). Enter the 9-digit SSN for each covered individual,
including the dashes. For covered individuals who are not the

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outside of the United States that does not count as hours of            hours of service for two or more ALE Members of the same 
service under section 4980H) is not an ALE Member.                      Aggregated ALE Group for the calendar month, those ALE 
                                                                        Members must treat one of the ALE Members as the employer of 
Bona fide volunteer. A bona fide volunteer is an employee of a 
                                                                        that employee for that calendar month. See One Form 1095-C 
government entity or tax-exempt organization whose only 
                                                                        for Each Employee of Each Employer for a discussion of 
compensation from that entity or organization is (1) 
                                                                        reporting in these circumstances. See Pub.15-A, Employer’s 
reimbursement for (or reasonable allowance for) reasonable 
                                                                        Supplemental Tax Guide, for more information on determining 
expenses incurred in the performance of services by volunteers, 
                                                                        who is an employee.
or (2) reasonable benefits (including length of service awards), 
and nominal fees, customarily paid by similar entities in               Note. In certain circumstances, an employee may have a 
connection with the performance of services by volunteers.              break in service (including a break in service due to a 
                                                                        termination of employment) during which the individual does not 
COBRA continuation coverage. COBRA continuation                         earn hours of service but, upon beginning to earn hours of 
coverage is health coverage that is required to be offered under        service again, the ALE Member must treat the individual as a 
the Consolidated Omnibus Budget Reconciliation Act of 1986              continuing employee rather than a new hire for purposes of 
(COBRA) in certain circumstances in which an employee or                certain rules under the regulations under section 4980H. See 
other individual covered under a health plan loses eligibility for      Regulations sections 54.4980H-3(c)(4) and 54.4980H-3(d)(6). 
coverage under that health plan (for example, because the               These rules do not impact whether the individual was an 
employee terminates employment or has a reduction in hours).            employee during the break in service, so the individual should 
For purposes of these instructions, COBRA continuation                  only be treated as an employee during the break in service for 
coverage also includes coverage required under any other                purposes of reporting if the individual remained an employee 
federal or state law that provides continuation coverage                during that period (and had not terminated employment with the 
comparable to that provided under COBRA. For additional                 ALE Member). For example, an employee on unpaid leave 
details, see section 4980B and Regulations sections 54.4980B-1          during the break in service would be treated as an employee for 
through 54.4980B-10.                                                    reporting purposes during the break in service, while a former 
Dependent. A dependent is an employee’s child, including a              employee whose employment had been terminated during the 
child who has been legally adopted or legally placed for adoption       break in service would not be treated as an employee for 
with the employee, who has not reached age 26. A child reaches          reporting purposes.
age 26 on the 26th anniversary of the date the child was born           Employee Required Contribution.   The Employee Required 
and is treated as a dependent for the entire calendar month             Contribution is the employee’s share of the monthly cost for the 
during which he or she reaches age 26. For this purpose, a              lowest-cost, self-only minimum essential coverage providing 
dependent does not include stepchildren, foster children, or a          minimum value that is offered to the employee by the ALE 
child that does not reside in the United States (or a country           Member. The employee share is the portion of the monthly cost 
contiguous to the United States) and who is not a United States         that would be paid by the employee for self-only coverage, 
citizen or national. For this purpose, a dependent does not             whether paid through salary reduction or otherwise.
include a spouse.                                                       For purposes of determining the amount of the employee’s 
Designated Governmental Entity (DGE).  A DGE is a person                share of the monthly cost, an ALE Member may divide the total 
or persons that are part of or related to the Governmental Unit         cost to the employee for the plan year by the number of months 
that is the ALE Member and that is appropriately designated for         in the plan year. This monthly amount of the employee’s share of 
purposes of these reporting requirements. For a Governmental            the cost would then be reported for any months of that plan year 
Unit that has delegated some or all of its reporting                    that fall within the 2023 calendar year. For example, if the plan 
responsibilities to a DGE for some or all of its employees, one         year begins January 1, the ALE Member may determine the 
Authoritative Transmittal must still be filed for that Governmental     amount to report for each month by taking the total annual 
Unit reporting aggregate employer-level data for all employees of       employee cost for all 12 months and dividing by 12. If the plan 
the Governmental Unit (including those for whom the                     year begins April 1, the ALE Member may determine the amount 
Governmental Unit has delegated its reporting responsibilities).        to report for January through March 2023, by taking the total 
For more information, see Authoritative Transmittal for Employers       annual employee cost for the plan year ending March 31, 2023, 
Filing Multiple Forms 1094-C, earlier.                                  and dividing by 12 (and reporting that amount for January, 
                                                                        February, and March 2023). Then, the ALE Member may 
Eligible employer-sponsored plan.      An eligible                      determine the monthly amount for April through December 2023 
employer-sponsored plan refers to group health coverage for             by taking the total annual employee cost for the plan year ending 
employees under (1) a governmental plan, such as the Federal            March 31, 2023, and dividing by 12 (and reporting that amount 
Employees Health Benefits Program (FEHB); (2) an insured plan           for April through December 2023).
or coverage offered in the small or large group market within a 
state; (3) a grandfathered health plan offered in a group market;       The Employee Required Contribution may not be the amount 
or (4) a self-insured group health plan for employees, including        the employee paid for coverage. For additional rules on 
an individual coverage HRA.                                             determining the amount of the Employee Required Contribution, 
                                                                        including for cases in which an ALE Member makes available 
Employee. An employee is an individual who is an employee               certain HRA contributions, cafeteria plan contributions, wellness 
under the common-law standard for determining employer–                 program incentives, and opt-out payments, see Regulations 
employee relationships. An employee does not include a sole             sections 1.5000A-3(e)(3)(ii) and 1.36B-2(c)(3)(v)(A). Also see 
proprietor, a partner in a partnership, an S corporation                Notice 2015-87.
shareholder who owns at least 2% of the S corporation, a leased 
employee within the meaning of section 414(n), or a worker that         Special rules apply for individual coverage HRAs. Generally, 
is a qualified real estate agent or direct seller.                      the Employee Required Contribution for the individual coverage 
                                                                        HRA means the required HRA contribution, as defined in 
If an employee is an employee of more than one ALE Member               Regulations section 1.36B-2(c)(5)(ii). However, for purposes of 
of the same Aggregated ALE Group during a calendar month,               the individual coverage HRA safe harbors in Proposed 
the employee is treated as an employee of the ALE Member for            Regulations section 54.4980H-5(f), the required contribution is 
whom the employee has the greatest number of hours of service           determined based on the applicable lowest cost silver plan, as 
for that calendar month; if the employee has an equal number of         defined in Proposed Regulations 54.4980H-5(f)(7)(iii), and the 

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monthly premium for the applicable lowest cost silver plan is        period preceding that stability period. (The look-back 
determined based on the employee’s age, as defined in                measurement method for identifying full-time employees is 
Proposed Regulations 54.4980H(f)(7)(i), and the employee’s           available only for purposes of determining and computing liability 
applicable location, as defined in Proposed Regulations              under section 4980H, and not for purposes of determining if the 
54.4980H(f)(7)(ii).                                                  employer is an Applicable Large Employer.) For purposes of 
For an employee offered an individual coverage HRA, the              both methods, 130 hours of service in a calendar month is 
Employee Required Contribution is the excess of the monthly          treated as the monthly equivalent of at least 30 hours of service 
premium for the applicable lowest cost silver plan based on the      per week.
employee’s applicable age over the monthly individual coverage            An ALE Member must report complete information for all 12 
HRA amount (generally, the annual individual coverage HRA            months of the calendar year for any of its employees who were 
amount divided by 12).                                               full-time employees for one or more months of the calendar year. 
Applicable lowest cost silver plan. Generally, the lowest            For more information on the identification of full-time employees, 
cost silver plan for an employee for a calendar month is the         including discussion of the monthly measurement method and 
lowest cost silver plan for self-only coverage of the employee       the look-back measurement method, and the rules for when an 
offered through the Exchange for the ZIP code of the employee’s      ALE Member may use one or both methods, see Regulations 
applicable location for the month. If there are different lowest     sections 54.4980H-1(a)(21) and 54.4980H-3, and Notice 
cost silver plans in different parts of a rating area, an employee’s 2014-49, 2014-41 I.R.B. 66 (describing a proposed approach to 
applicable lowest cost silver plan is the lowest cost silver plan in the application of the look-back measurement method in 
the part of the rating area in which the employee’s applicable       situations in which the measurement period applicable to an 
location is located. The lowest cost silver plan for an employee is  employee changes).
the lowest cost silver plan for the lowest age band in the                Note. A former employee (for example, a retiree) is not a 
individual market for the employee’s applicable location. For        full-time employee for any month after termination of 
more information, see Employer Lowest Cost Silver Plan               employment with the ALE Member. However, if the former 
Premium Look-up Table.                                               employee was a full-time employee for any month of the 
Applicable age.     For an employee who is or will be eligible for   calendar year (for example, before retiring mid-year), the ALE 
an individual coverage HRA on the first day of the plan year, the    Member must complete information in Part II of Form 1095-C for 
employee’s applicable age for the plan year is the employee’s        all 12 months of the calendar year, using the appropriate codes.
age on the first day of the plan year. For an employee who                    An ALE Member need not file a Form 1095-C for an 
becomes eligible during the plan year, the employee’s applicable          TIP individual who for each month of a calendar year is 
age for the remainder of the plan year is the employee’s age on               either not an employee of the ALE Member or is an 
the date the individual coverage HRA can first become effective      employee in a Limited Non-Assessment Period with respect to 
for that employee. Note that for non-calendar year plans or for      section 4980H(b). However, for the months in which the 
employees who become eligible during the plan year, the              employee was an employee of the ALE Member, such an 
applicable age may not be the age reported in Part II of Form        employee would be included in the total employee count 
1095-C.                                                              reported on Form 1094-C, Part III, column (c). Also, if during the 
Applicable location.   An employee’s applicable location is          Limited Non-Assessment Period the employee enrolled in 
where the employee resides for the calendar month, or if the ALE     coverage under a self-insured, employer-sponsored plan, the 
Member is applying the location safe harbor, the employee’s          ALE Member must file a Form 1095-C for the employee to report 
primary site of employment for the calendar month.                   coverage information for the year.
Employer. For purposes of these instructions, an employer is 
the person that is the employer of an employee under the             Full-time equivalent employees.   A combination of employees, 
common-law standard for determining employer–employee                each of whom individually is not treated as a full-time employee 
relationships and that is subject to the employer shared             because he or she is not employed on average at least 30 hours 
responsibility provisions of section 4980H (these employers are      of service per week with an employer, but who, in combination, 
referred to as ALE Members). For more information on which           are counted as the equivalent of a full-time employee solely for 
employers are ALE Members, see the definitions of Applicable         purposes of determining whether the employer is an ALE. For 
Large Employer (ALE) and Applicable Large Employer Member            rules on how to determine full-time equivalent employees, see 
(ALE Member).                                                        Regulations section 54.4980H-2(c).
Full-time employee.   For purposes of Forms 1094-C and               Governmental Unit and Agency or Instrumentality of a Gov-
1095-C, the term “full-time employee” means a full-time              ernmental Unit. A Governmental Unit is the government of the 
employee, as defined under section 4980H and the related             United States, any state or political subdivision thereof, or any 
regulations, rather than any other definition of that term that the  Indian tribal government (as defined in section 7701(a)(40)) or 
ALE Member may use for other purposes. Accordingly, a                subdivision of an Indian tribal government (as defined in section 
full-time employee is an employee who, for a calendar month, is      7871(d)). For purposes of these instructions, references to a 
determined to be a full-time employee under either the monthly       Governmental Unit include an Agency or Instrumentality of a 
measurement method or the look-back measurement method               Governmental Unit. Until guidance is issued that defines the 
(as applicable to that employee). The monthly measurement            term “Agency or Instrumentality of a Governmental Unit” for 
method and the look-back measurement method are the two              purposes of section 6056, an entity may determine whether it is 
methods provided under the section 4980H regulations for             an Agency or Instrumentality of a Governmental Unit based on a 
determining whether an employee has sufficient hours of service      reasonable and good faith interpretation of existing rules relating 
to be a full-time employee. Under the monthly measurement            to agency or instrumentality determinations for other federal tax 
method, a full-time employee is an employee who was employed         purposes.
an average of at least 30 hours of service per week with the ALE     Health coverage.  As used in these instructions, health 
Member during a calendar month. Under the look-back                  coverage refers to minimum essential coverage, unless 
measurement method, an employee is a full-time employee for          otherwise indicated.
each month of the stability period selected by the ALE Member if 
the employee was employed an average of at least 30 hours of         Hours of service. An hour of service is each hour for which an 
service per week with the ALE Member during the measurement          employee is paid, or entitled to payment, for the performance of 

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duties for the employer, and each hour for which an employee is           determine whether a new employee is a full-time employee, and 
paid, or entitled to payment, for a period of time during which no        the employee is a variable hour employee, seasonal employee, 
duties are performed due to vacation, holiday, illness, incapacity        or part-time employee, the initial measurement period for that 
(including disability), layoff, jury duty, military duty, or leave of     employee and the administrative period immediately following 
absence. An hour of service does not include any hour of service          the end of that initial measurement period.
performed as a bona fide volunteer of a government entity or              • Period following change in status that occurs during initial 
tax-exempt entity, as part of a Federal Work-Study Program (or a          measurement period under the look-back measurement method. 
substantially similar program of a state or political subdivision         If an ALE Member is using the look-back measurement method 
thereof) or to the extent the compensation for services                   to determine whether a new employee is a full-time employee, 
performed constitutes income from sources outside the United              and, as of the employee’s start date, the employee is a variable 
States. For additional rules for determining hours of service, see        hour employee, seasonal employee, or part-time employee, but, 
Regulations sections 54.4980H-1(a)(24) and 54.4980H-3(b),                 during the initial measurement period, the employee has a 
and Notice 2015-87, Q&A 14, at IRS.gov/irb/2015-52_IRB/                   change in employment status such that, if the employee had 
ar11.html. See section VI of the preamble to the section 4980H            begun employment in the new position or status, the employee 
regulations for a discussion of determination of hours of service         would have reasonably been expected to be a full-time 
for categories of employees for whom the general rules for                employee, the period beginning on the date of the employee’s 
determining hours of service may present special difficulties             change in employment status and ending not later than the end 
(including adjunct faculty and commissioned salespeople) and              of the third full calendar month following the change in 
certain categories of work hours associated with some positions           employment status. If the employee is a full-time employee 
of employment, including layover hours (for example, for certain          based on the initial measurement period and the associated 
airline employees), on-call hours, and work performed by an               stability period starts sooner than the end of the third full 
individual who is subject to a vow of poverty as a member of a            calendar month following the change in employment status, this 
religious order.                                                          Limited Non-Assessment Period ends on the day before the first 
                                                                          day of that associated stability period.
Individual coverage HRA.    An HRA is a type of account-based 
health plan that employers can use to reimburse employees for             • First calendar month of employment. If the employee’s first 
                                                                          day of employment is a day other than the first day of the 
their medical care expenses. An individual coverage HRA is an 
                                                                          calendar month, then the employee’s first calendar month of 
HRA integrated with individual health insurance coverage or 
                                                                          employment is a Limited Non-Assessment Period.
Medicare, subject to certain conditions. For more information 
about individual coverage HRAs, see T.D. 9867 and IRS.gov/                Minimum essential coverage (MEC).       Although various types 
Newsroom/Health-Reimbursement-Arrangements-HRAs.                          of health coverage may qualify as minimum essential coverage, 
                                                                          for purposes of these instructions, minimum essential coverage 
Limited Non-Assessment Period. A Limited Non-Assessment 
                                                                          refers to health coverage under an eligible employer-sponsored 
Period generally refers to a period during which an ALE Member 
                                                                          plan. An individual coverage HRA is a self-insured group health 
will not be subject to an assessable payment under section 
                                                                          plan and an eligible employer sponsored plan. For more details 
4980H(a) and, in certain cases, section 4980H(b), for a full-time 
                                                                          on minimum essential coverage, see Minimum essential 
employee, regardless of whether that employee is offered health 
                                                                          coverage in Pub. 974.
coverage during that period.
  The first five periods described below are Limited                      Minimum value. A plan provides minimum value if the plan 
Non-Assessment Periods with respect to sections 4980H(a) and              pays at least 60% of the costs of benefits for a standard 
4980H(b) only if the employee is offered health coverage by the           population and provides substantial coverage of in-patient 
first day of the first month following the end of the period. Also,       hospitalization services and physician services. An individual 
the first five periods described below are Limited                        coverage HRA that is affordable is treated as providing minimum 
Non-Assessment Periods for section 4980H(b) only if the health            value.
coverage that is offered at the end of the period provides                Offer of health coverage. An ALE Member makes an offer of 
minimum value. For more information on Limited                            coverage to an employee if it provides the employee an effective 
Non-Assessment Periods and the application of section 4980H,              opportunity to enroll in the health coverage (or to decline that 
see Regulations section 54.4980H-1(a)(26).                                coverage) at least once for each plan year. For this purpose, the 
• First year as ALE period. January through March of the first            plan year must be 12 consecutive months unless a short plan 
calendar year in which an employer is an ALE, but only for an             year of less than 12 consecutive months is permitted for a valid 
employee who was not offered health coverage by the employer              business purpose. An ALE Member makes an offer of health 
at any point during the prior calendar year.                              coverage to an employee for the plan year if it continues the 
• Waiting period under the monthly measurement method. If an              employee’s election of coverage from a prior year but provides 
ALE Member is using the monthly measurement method to                     the employee an effective opportunity to opt out of the health 
determine whether an employee is a full-time employee, the                coverage. If an ALE Member provides health coverage to an 
period beginning with the first full calendar month in which the          employee but does not provide the employee an effective 
employee is first otherwise (but for completion of the waiting            opportunity to decline the coverage, the ALE Member is treated 
period) eligible for an offer of health coverage and ending no            as having made an offer of health coverage to the employee only 
later than 2 full calendar months after the end of that first             if that health coverage provides minimum value and does not 
calendar month.                                                           have an Employee Required Contribution for the coverage for 
• Waiting period under the look-back measurement method. If               any calendar month of more than 9.5% (as adjusted) of a 
an ALE Member is using the look-back measurement method to                monthly amount determined as the mainland federal poverty line 
determine whether an employee is a full-time employee and the             for a single individual for the applicable calendar year, divided by 
employee is reasonably expected to be a full-time employee at             12.
his or her start date, the period beginning on the employee’s 
                                                                            For purposes of reporting, an offer to a spouse includes an 
start date and ending not later than the end of the employee’s 
                                                                          offer to a spouse that is subject to one or more reasonable, 
third full calendar month of employment.
                                                                          objective conditions, regardless of whether the reasonable, 
• Initial measurement period and associated administrative 
                                                                          objective conditions are satisfied. For example, an offer of 
period under the look-back measurement method. If an ALE                  coverage that is available to a spouse only if the spouse certifies 
Member is using the look-back measurement method to 
                                                                          that the spouse does not have access to health coverage from 

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another employer is treated as an offer of coverage to the all calendar months during the calendar year for which the
spouse for reporting purposes. Note that this treatment is for employee was a full-time employee for whom a section 4980H
reporting purposes only, and will generally not affect the assessable payment could apply, with an Employee Required
spouse’s eligibility for the premium tax credit if the spouse did Contribution for each month, not exceeding 9.5 % (as adjusted)
not meet the condition and therefore did not have an actual offer of the mainland single federal poverty line divided by 12,
of coverage. A conditional offer to a spouse is reported by provided that the offer includes an offer of MEC to the
entering code 1J or 1K (as applicable) on line 14 of Form employee’s spouse and dependents (if any).
1095-C. See the instructions for line 14 for more information. An
offer to a dependent does not include an offer to a dependent Privacy Act and Paperwork Reduction Act Notice. We ask
that is subject to one or more reasonable, objective conditions for the information on these forms to carry out the Internal
unless the dependent satisfies the conditions and the dependent Revenue laws of the United States and the Patient Protection
actually had an offer of coverage. In addition, an offer of and Affordable Care Act. Our legal right to ask for the information
coverage is treated as made to an employee’s dependents only on this form is Internal Revenue Code sections 6055, 6056,
if the offer of coverage is made to an unlimited number of 4980H, and their regulations. We request it to confirm that you
dependents regardless of the actual number of dependents, if are providing your employees offers of, and enrollment in, health
any, an employee has during any particular calendar month. coverage and to determine the employer shared responsibility
An ALE Member offers health coverage for a month only if it payments and eligibility of your employees for premium tax
offers health coverage that would provide coverage for every day credits. If you do not provide this information, we may be unable
of that calendar month. For reporting purposes, this means that to determine whether your employees are entitled to premium
an offer of coverage does not occur for a month if an employee’s tax credits. Providing false or fraudulent information may subject
employment terminates before the last day of a calendar month you to penalties. We may disclose this information to the
and the health coverage also ends before the last day of that Department of Justice for civil or criminal litigation and to cities,
calendar month (or for an employee who did not enroll in states, and the District of Columbia for use in administering their
coverage, the coverage would have ended if the employee had tax laws. We may also disclose this information to other
enrolled in coverage). However, see the description of Code countries under a tax treaty, to federal and state agencies to
Series 2—Section 4980H Safe Harbor Codes and Other Relief enforce federal nontax criminal laws, or to federal law
for Employers, code 2B, which may be applicable in these enforcement and intelligence agencies to combat terrorism.
circumstances to indicate that the ALE Member is treated as
having offered coverage for the entire month for purposes of You are not required to provide the information requested on
section 4980H. a form that is subject to the Paperwork Reduction Act unless the
form displays a valid OMB control number. Books or records
An ALE Member offers health coverage to an employee if it, relating to a form or its instructions must be retained as long as
or another employer in the Aggregated ALE Group, or a third their contents may become material in the administration of any
party, such as a multiemployer or single employer Taft-Hartley Internal Revenue law. Generally, tax returns and return
plan, a multiple employer welfare arrangement (MEWA), or, in information are confidential, as required by section 6103.
certain cases, a staffing firm, offers health coverage on behalf of
the employer. See Regulations sections 54.4980H-4(b)(2) and The time needed to complete and file this form will vary
54.4980H-5(b). depending on individual circumstances. The estimated average
Interim Guidance Regarding Multiemployer time is:
TIP Arrangements. An ALE Member is treated as offering
health coverage to an employee if the ALE Member is Form 1094-C. . . . . . . . . . . . . . . . . . 4 hr.
required by a collective bargaining agreement or related
participation agreement to make contributions for that employee Form 1095-C. . . . . . . . . . . . . . . . . . 12 min.
to a multiemployer plan that offers, to individuals who satisfy the
plan’s eligibility conditions, health coverage that is affordable and
provides minimum value, and that also offers health coverage to
those individuals’ dependents. For more information, see If you have comments concerning the accuracy of these time
section XV.E of the preamble to the final regulations under estimates or suggestions for making this form simpler, we would
section 4980H. This relief is referred to as the “multiemployer be happy to hear from you. You can send us comments from
arrangement interim guidance” and the “multiemployer interim IRS.gov/FormComments. Or you can write to the Internal
rule relief” in these instructions. Revenue Service, Tax Forms and Publications Division, 1111
Constitution Ave. NW, IR-6526, Washington, DC 20224. Don't
Qualifying Offer. A Qualifying Offer is an offer of MEC send the form to this office.
providing minimum value to one or more full-time employees for

-18- Instructions for Forms 1094-C and 1095-C (2023)

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