JOB AID: FORM 1095-A. January 9, 2015

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Alan McCoy
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Your destination for affordable, quality health care, including Medi-Cal January 9, 2015 Covered California provides an annual notice to Consumers, which includes a cover letter and the Health

(This notice is not generated for plans purchased through the Small Business Health Options Program, called SHOP).

Agents (Agents), County Eligibility Workers (CEWs), Plan Based Enrollers (PBEs), and Service Center Representatives (SCRs).

online, the Consumer must log into their Covered California account.

1 Your destination for affordable, quality health care, including Medi-Cal January 9, 2015 Covered California provides an annual notice to Consumers, which includes a cover letter and the Health Insurance Marketplace Statement (Form 1095-A), to provide the household coverage information needed for tax filing purposes. The Form 1095-A is generated for each plan that is effectuated (i.e., the first premium payment has been made) through Covered California during the previous year, regardless if premium assistance was received. (This notice is not generated for plans purchased through the Small Business Health Options Program, called SHOP). The cover letter and the Form are generated in PDF format as a hardcopy (paper) document to mail to the Consumer, and as an electronic document to be sent to the Secure Mailbox associated with the Consumer s account. This Job Aid reviews functionality to view the notice and provides an overview of documents that comprise the notice and is intended for Certified Enrollment Counselors (CECs), Certified Insurance Agents (Agents), County Eligibility Workers (CEWs), Plan Based Enrollers (PBEs), and Service Center Representatives (SCRs). Secure Mailbox Covered California mails a paper copy of the notice to the Consumer and sends the electronic copy of the notice to the Secure Mailbox associated with the Consumer s account. To view the notification online, the Consumer must log into their Covered California account. Once the Consumer has logged in, clicking the Secure Mailbox link above the Global Header navigates the Consumer to their Inbox where they may view, download and print their Form 1095-A. Keep in mind the Consumer s Secure Mailbox link does not display for CECs, CEWs, Agents, PBEs or SCRs viewing a Consumer s case. Note: It may be necessary to download software (for example, a free Adobe Acrobat reader) to be able to view, download, and print the document. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 1 of 17

Documents and Correspondence Page After the Form 1095-A notice is delivered to the Consumer s Secure Mailbox, the notice can be

For SCRs and CEWs: To view the notice, search and select the Individual from the Administration Home page, click the View Case

then click the Documents and Correspondence tab to navigate to the Documents and Correspondence page where the notice will

2 There may also be a popup after the document link is clicked to prompt the download of a font package if applicable, to display text other than English correctly. Click the OK button to continue, if needed. Click the Cancel button to cancel. Documents and Correspondence Page After the Form 1095-A notice is delivered to the Consumer s Secure Mailbox, the notice can be viewed on the Documents and Correspondence page for the case. For SCRs and CEWs: To view the notice, search and select the Individual from the Administration Home page, click the View Case button then click the Documents & Correspondence tab to navigate to the Documents and Correspondence page where the notice will be listed. For Consumers, CECs, Agents and PBEs: To view the notice from the Consumer s case, click Summary on the Individual Landing page, then click the Documents and Correspondence tab to navigate to the Documents and Correspondence page where the notice will be listed. CalNOD62A- Health Insurance Marketplace Statement The CalNOD62A notice is generated annually for each Individual policy purchased through Covered California in the previous year. The Consumer will CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 2 of 17

3 receive a hardcopy (paper) notice in the mail and an electronic PDF copy is also available in the Consumer s Secure Mailbox. The CalNOD62A notice is generated after the close of the tax year and includes the following documents: Cover Letter A Form 1095-A Health Insurance Marketplace Statement for each plan (including plan and plan level changes) The notice is addressed to the household Tax Filer (or to the Primary Contact when no tax filer information is available). The notice explains why the Consumer is receiving the notice, describes how premium assistance affects tax filing, defines steps to reconcile premium assistance, identifies ways to get help with tax filing, and includes the Form 1095-A Instructions for Recipient. The notice advises Consumers to contact Covered California right away if they think there is a mistake on the Form 1095-A and informs that Covered California cannot provide tax advice. A draft copy of CalNOD62A is provided on the following pages: CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 3 of 17

4 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 4 of 17

5 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 5 of 17

6 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 6 of 17

7 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 7 of 17

8 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 8 of 17

9 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 9 of 17

10 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 10 of 17

11 Health Insurance Marketplace Statement (Form 1095-A) CalHEERS uses all household coverage information for the previous calendar year to generate the Form 1095-A for each effectuated Individual Covered California health insurance policy. The information provided on the Form 1095-A is used for tax filing purposes to reconcile premium assistance and claim tax credits. The information presented is also provided to the Internal Revenue Service (IRS). A separate Form 1095-A is generated per policy, including for each plan change or plan level change (for example, when a bronze plan is changed to a silver plan), during the previous enrollment year. When multiple Form 1095-As are generated for the same tax filing household, they are bundled together as one notice. If multiple families are enrolled in a single qualified health plan (QHP), a Form 1095-A is generated to each Tax Filer (or Primary Contact). For example, if a single QHP is shared among two or more households, each Tax Filer will receive a separate Form 1095-A which reports information about their household s enrollment in that policy for tax filing purposes. Form 1095-A is a two page IRS document. Page 1 of the Form provides the household coverage information in three parts: Recipient Information, Coverage Household and Household Information. Page 2 provides the Instructions for Recipient. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 11 of 17

12 Key Data Fields For Form 1095-A Form 1095-A Part I Part I of the IRS Form 1095-A is prepopulated with recipient and policy information. Note the term recipient refers to the Tax Filer or Primary Contact. Only the last four digits of social security numbers of household members will display for security reasons. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 12 of 17

Part III Part III of the IRS Form 1095-A is prepopulated with the Monthly Premium Amount, the Monthly Premium Amount of Second Lowest Cost Silver Plan (SLCSP) and the Monthly Advance Payment of the

13 Form 1095-A Part II Part II of the IRS Form 1095-A is prepopulated with information regarding members of the coverage household. If there are more than five family members in the coverage household, additional pages will be provided to continue this section. Part III Part III of the IRS Form 1095-A is prepopulated with the Monthly Premium Amount, the Monthly Premium Amount of Second Lowest Cost Silver Plan (SLCSP) and the Monthly Advance Payment of the Premium Tax Credit (APTC), if any, for each month of the coverage year. If the household did not receive APTC for a month, the field will be blank. Consumers should be advised that Covered California has determined the Monthly Premium Amount of SLCSP which applies to the household member s coverage. The SLCSP was used to compute the amount of APTC and the premium tax credit. Keep in mind that the notice is generated regardless if premium assistance was received and that the Form 1095-A is populated with the SLCSP regardless if the household accepted APTC. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 13 of 17

14 CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 14 of 17

15 Instructions for Recipient Page 2 of Form 1095-A provides instructions for the recipient. Consumers should be aware that the information on the Form 1095-A is needed to complete IRS Form 8962, Premium Tax Credit (PTC), for attachment to the Consumer s IRS Form 1040, Form 1040A or Form 1040NR. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 15 of 17

CalNOD62B Corrected Health Insurance Marketplace Statement The CalNOD62B notice is only generated when corrections are made to information on the initial Form 1095-A, as a result of data changes

16 CalNOD62B Corrected Health Insurance Marketplace Statement The CalNOD62B notice is only generated when corrections are made to information on the initial Form 1095-A, as a result of data changes identified by CalHEERS. If a Consumer reports a mistake on their Form 1095-A, Report a Change functionality can be used to update the data. Changes for the previous year submitted via the Report a Change process made after the original Form 1095-A has been generated may trigger a CalNOD62B. Keep in mind that changes to a household member s social security number or date of birth are retroactive to the beginning coverage date for the member. Note: If the update cannot be made using the Report a Change functionality (for example, Report a Change for 2014 has ended), refer to Covered California policy and procedure for the appropriate process for making the necessary CalHEERS data changes so that the corrected Form 1095-A can be generated for the Consumer. CalNOD62B is marked as a revision and explains the Consumer is receiving the corrected form because a correction was made. The notice advises Consumers that Covered California cannot provide tax advice. Note that the Tax Filer (or Primary Contact) will not receive a CalNOD62B unless data on their initial Form 1095-A is corrected. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 16 of 17

Corrected Health Insurance Marketplace Statement (Form 1095-A) When CalNOD62B is generated due to a correction to the initial Form 1095-A, the Corrected checkbox is marked on the updated Form 1095-A

17 Corrected Health Insurance Marketplace Statement (Form 1095-A) When CalNOD62B is generated due to a correction to the initial Form 1095-A, the Corrected checkbox is marked on the updated Form 1095-A to identify it as a corrected version. Notice Availability The CalNOD62A (and the CalNOD62B, if necessary) is available in English, Spanish, Korean, Vietnamese, or Chinese, and generated in the preferred language documented in the Consumer s case. CalNOD62A is available on or before January 31st of each calendar year, beginning with The paper document is postmarked no later than January 31. CalNOD62B, if generated for a correction to the initial Form 1095-A, is generated on a biweekly basis as needed, when changes are identified, beginning in mid-february. Paper Document Mailing Envelope Covered California mails the paper copy of the notice to the Household Tax Filer or Primary Contact s mailing address. Envelopes used to mail the CalNOD62A and CalNOD62B display a Covered California image and message in English, Spanish, Chinese, Vietnamese, and Korean languages on the address side of the envelope, regardless of the notice print language. CoveredCA.com is a joint initiative between Covered California and the California Department of Health Care Services Page 17 of 17

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