1095-C Decoder Sample Form

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1095-C
1095-C Decoder Sample Form

Form 1095-C Decoder

If you were a full-time employee working 30 or more hours per week or enrolled in healthcare coverage from your employer at any point in 2020, you should receive a Form 1095-C. If you received a Form 1095-C from your employer and you're not sure what the codes mean, check out our 1095-C Decoder to learn more.

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Lines 1-13 Line 14 Line 15 Line 16 Lines 17 Lines 18-30

Part 1 of the form includes information about you and your employer.

Part 2 of the form includes information about the coverage offered to you by your employer, the affordability of the coverage offered, and the reason why you were or were not offered coverage by your employer. The information must be reported on a month-by-month basis unless the information is the same for all 12 months.

Line 14 is used to report whether an offer of coverage was made to an employee for each month of the year.

Code:	What it means
1A	Your employer made a qualifying offer of healthcare coverage that is affordable based on the federal poverty line to you, your spouse, and your dependent(s), if any.
1B	Your employer made a qualifying offer of healthcare coverage to you.
1C	Your employer made a qualifying offer of healthcare coverage to you and your dependent(s).
1D	Your employer made a qualifying offer of healthcare coverage to you and your spouse.
1E	Your employer made a qualifying offer of healthcare coverage to you, your spouse, and your dependent(s).
1F	Your employer made an offer of healthcare coverage to you, your spouse, and your dependent(s), if any, that does not qualify as providing "minimum value".
1G	You were not a full-time employee but were enrolled in healthcare coverage.
1H	Your employer did not make an offer of coverage or the offer was not a qualified offer.
1I	Reserved. This code was used for transition relief for tax year 2015. It no longer applies for 2017 reporting but may be used for a different purpose in future years.
1J	Your employer made a qualifying offer of healthcare coverage to you and a conditional offer of coverage to your spouse.
1K	Your employer made a qualifying offer of healthcare coverage to you and your dependent(s) and made a conditional offer of coverage to your spouse.
1L	Your employer offered you an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary residence location ZIP code.
1M	Your employer offered you and your dependent(s) an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary residence location ZIP code.
1N	Your employer offered you, your dependent(s), and spouse an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary residence location ZIP code.
1O	Your employer offered you an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary employment site ZIP code.
1P	Your employer offered you and your dependent(s) an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary employment site ZIP code.
1Q	Your employer offered you, your dependent(s), and spouse an Individual coverage health reimbursement arrangement (HRA) and the affordability was determined by using your primary employment site ZIP code.
1R	Your employer offered you, and spouse or dependents an Individual coverage HRA that is NOT affordable.
1S	Your employer offered you an Individual coverage HRA when you were not a full-time employee.

Part 2 of the form includes information about the coverage offered to you by your employer, the affordabilityof the coverage offered, and the reason why you were or were not offered coverage by your employer. The information must be reported on a month-by-month basis unless the information is the same for all 12 months.

Line 15 is used to report your share of the lowest-cost monthly premium for self-only qualifying coverage. The amount reported on line 15 may not be the amount you paid for coverage if, for example, you chose to enroll in more expensive coverage such as family coverage. Line 15 will show an amount only if code 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, or 1Q is entered on line 14. If you were offered coverage but not required to contribute any amount towards the premium, this line will report a "0.00" for the amount.

Line 16 explains why your employer did or did not offer you coverage.This line provides the IRS information needed to determine whether your employer satisfied the employer mandate. None of this information affects your eligibility for the premium tax credit.

Code:	What it means
2A	You did not work any day in the month.
2B	You were not full-time during the month.
2C	You were enrolled in coverage for the entire month.
2D	You were in a waiting period and not yet eligible for coverage per the Affordable Care Act regulations.
2E	You were covered by a Union plan.
2F	Your employer offered you coverage that was considered affordable based on your W-2 wages, but you did not enroll.
2G	Your employer offered you coverage that was considered affordable based on the federal poverty line, but you did not enroll.
2H	Your employer offered you coverage that was considered affordable based on your rate of pay, but you did not enroll.

Line 17 shows the ZIP code used for affordability when offered an individual coverage HRA. You will see your primary residence location if code 1L, 1M, or 1N was entered in Line 14. You will see your primary employment location if code 1O, 1P, or 1Q was entered in Line 14.

Part 3 of the form includes information about you and the individuals (including dependents) covered under your self-insured plan.

While Part 2 will tell the IRS if your employer offered coverage, Part 3 shows who accepted the offer and is actually covered.The box will be checked for any month that you were enrolled in coverage for at least one day. For example, if you enrolled in coverage on July 31, the box will be checked for the month of July.