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Page 2 of 3 Fileid: … ons/i1095a/2023/a/xml/cycle04/source 11:01 - 29-Sep-2023
The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
claim other family members as dependents, and who, if Column A. Enter the total monthly enrollment premiums
qualified, would take the premium tax credit for the year of for the policy in which the covered individuals enrolled.
coverage for his or her tax family). If the tax filer can't be Include only the premiums allocable to essential health
identified from the information provided at enrollment (for benefits. If a covered individual is enrolled in a
example, because no financial assistance was stand-alone dental plan, include the portion of the
requested), enter the name of the primary applicant for the premiums for the stand-alone dental plan that is allocable
coverage. to pediatric dental coverage in the total monthly
Line 5. Enter the social security number (SSN) for the enrollment premiums. If more than one Form 1095-A is
recipient shown on line 4. filed for coverage of the recipient’s family for the same
months because, for example, a family member enrolled
Line 6. Enter the recipient’s date of birth only if line 5 is in a separate policy, include the portion of the premium for
blank. pediatric dental coverage in the amount in column A on
Lines 7, 8, and 9. Enter information about the recipient’s only one Form 1095-A. If more than one tax filer is
spouse, if the recipient has one, if advance credit enrolled in a policy, report on each tax filer's Form 1095-A
payments were made for the coverage. Enter this only those enrollment premiums allocated to that tax filer.
information even if the advance credit payments were not If a policy is terminated by an issuer for nonpayment of
made for the spouse's coverage. Enter a date of birth only premiums, enter -0- for a month in which the covered
if line 8 is blank. individuals have coverage but the premiums are not fully
paid (generally, the first month of a grace period). If one or
Line 10. Enter the date that coverage under the policy
more covered individuals terminate coverage before the
started. If the policy was in effect at the start of the year,
last day of a month, the amount reported in this column
enter 1/1/2023.
should not include any amount of the monthly enrollment
Line 11. Enter the date of termination if the policy was premium that was refunded. If the issuer provided a
terminated during the year. If the policy was in effect at the premium credit for one or more months, the amount
end of the year, enter 12/31/2023. reported in this column should be the amount of the
Lines 12–15. Enter the recipient's address. monthly enrollment premium as reduced by any premium
credit.
Part II—Covered Individuals Column B. Enter the premiums for the applicable second
Enter on lines 16 through 20 and columns A through E lowest cost silver plan (SLCSP) that was used as a
information for each individual covered under the policy, benchmark to compute monthly advance credit payments.
including the recipient and the recipient's spouse, if If advance payments were made, the applicable SLCSP
covered. If advance credit payments were not made for for a month is the SLCSP that applies to individuals in Part
any coverage under the policy and a tax family cannot be II who were identified at enrollment as members of the tax
identified, enter in Part II information for all covered filer's tax family (the tax filer, the tax filer's spouse if the tax
individuals. If advance credit payments were made for the filer is filing a joint return with her or his spouse, and any
coverage or a tax family can be identified, enter in Part II dependents of the tax filer) and who are enrolled in the
information only for covered individuals whom the tax filer coverage on the first day of the month and are not eligible
certified at enrollment would be a part of the tax filer's tax for other health coverage for that month. However, if an
family. Information about individuals enrolled in the same individual enrolls in coverage and the enrollment is
policy as the tax filer’s tax family who are not members of effective on the date of the individual's birth, adoption,
that tax family, including children, must be reported on a placement in foster care, or on the effective date of a court
separate Form 1095-A. order, the individual should be considered to have
enrolled on the first day of the month for purposes of the
For each line, enter a date of birth in column C only if
applicable SLCSP premium reported in column B. If all
column B is blank. Enter in column D the date the
covered individuals enroll after the first of the month, and
coverage started for the individual. Enter in column E the no individual's coverage is effective on the date of the
date of termination if the individual's coverage was
individual's birth, adoption, placement in foster care, or on
terminated during the year. If the coverage was in effect at
the effective date of a court order, enter -0- in column B for
the end of the year, enter 12/31/2023.
that month. If more than one Form 1095-A is filed for
If there are more than five covered individuals, coverage of a tax filer’s family for the same month (for
TIP complete one or more additional Forms 1095-A, example, because members of the family were split
Part II. among several policies), enter the SLCSP premium that
applies to all the family members who were enrolled in any
Part III—Coverage Information policy on the first of the month and who were not eligible
for other health coverage for that month. Enter this SLCSP
Enter information in Part III, lines 21 through 32, for each
premium in column B on each Form 1095-A.
month of coverage. This information is determined on a
monthly basis and may change during the year if there is a In some cases, the information provided at enrollment
change in enrollment or other circumstances that affect may not indicate which covered individuals are members
eligibility for, or the amount of, the premium tax credit. of the recipient's family and are not eligible for other health
Total the amounts on lines 21 through 32 and enter on coverage. (Such information may not be provided, for
line 33. example, because no financial assistance was
requested.) If this is the case, and if the Marketplace has
-2- Instructions for Form 1095-A (2023)
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