Darcy L. Hitesman. MACA/MCHRMA Conference September 10, 2015 MACA/MCHRMA 9/10/15

Transcription

1 Darcy L. Hitesman MACA/MCHRMA Conference September 10, 2015 MACA/MCHRMA 9/10/15 1

2 Two new reporting requirements beginning in 2016 Caution: Based on 2015 calendar year data. Reporting requirement not tied to whether penalty assessable in 2015 Minimum Essential Coverage (MEC) Reporting Code 6055 Completed by any person providing MEC To facilitate enforcement on individual mandate Applicable Large Employer (ALE) Reporting Code 6056 Completed by an ALE (special rule for controlled groups and governmental entities) To facilitate enforcement of Employer Shared Responsibility (a/k/a Play or Pay) MACA/MCHRMA 9/10/15 2

3 Self-Insured Plan Type Insured EMPLOYER SIZE ALE Not ALE 1094/1095 C [as employer; as provider] 1094/1095 B [as provider] 1094/1095 C [as employer] None MACA/MCHRMA 9/10/15 3

4 Draft 2015 Forms pre-released June 2015 Very little difference from 2014 Forms Addition of Plan Start Month on Form 1095-C Draft 2015 instructions *Web citations for both Draft 2015 form and Draft 2015 Instructions on handouts MACA/MCHRMA 9/10/15 4

5 Focus on the two forms How to complete What information need to have so can complete Comprehensive but not exhaustive Not addressing other aspects such as: Deadlines and methods for filing Notification options and deadlines Penalties for failure to file Etc. MACA/MCHRMA 9/10/15 5

6 Make sure you are an applicable large employer (ALE) Know whether insured or self-insured Determine what lines need to be completed Also tells you what information you will need Are you currently gathering? Recommend circle lines required to be completed Double check lines not circled Cross through lines not required to be completed YOU CAN DO THIS NOW. What for final releases MACA/MCHRMA 9/10/15 6

7 IRS Form 1094-C (Draft 2015) MACA/MCHRMA 9/10/15 7

8 Form 1094-C is a transmittal form Accompanies 1095-C forms when submitted to IRS ALE Member (see definition on p.12 of 2015 draft instructions) Includes single employer Includes member of an Aggregated ALE Group Aggregated AE Group refers to controlled group for purposes of the Code Know whether you are part of aggregated ALE Group Lines 7 and 8 identify the person responsible for answering any questions MACA/MCHRMA 9/10/15 8

9 Lines 9 15 are for governmental entities only Example of DGE on p.2 of 2015 draft instructions DGE described on p. 9 of 2015 draft instructions DGE defined on p.12 of 2015 draft instructions Ability to use DGE for some but not all purposes (see p.12 of 2015 draft instructions) MACA/MCHRMA 9/10/15 9

10 Line 18, total number of 1095-C forms transmitted under this 1094-C Can be more than one transmittal MACA/MCHRMA 9/10/15 10

11 Line 19, Authoritative transmittal One transmittal must be designated authoritative and report aggregate employer-level data If only one transmittal being filed, it is the authoritative transmittal Lines completed only if authoritative transmittal MACA/MCHRMA 9/10/15 11

12 Line 20, total Forms 1095-C for ALE member Compare to Line 18; if single employer filing only one 1094-C, Line 20 should be same as 18 MACA/MCHRMA 9/10/15 12

13 Line 21, whether part of Aggregated ALE Group (i.e., controlled group) Need to know whether are or are not part of Aggregated ALE Group Document analysis If not part of Aggregated ALE Group, do not have to complete Part IV MACA/MCHRMA 9/10/15 13

14 Line 22, Certifications of Eligibility [later slide] Remember only completing Line 22 if authoritative transmittal (see Line 19) MACA/MCHRMA 9/10/15 14

15 Signature block Examined return and accompanying documents Penalty of perjury Practical matter difficult to challenge penalty applicability and calculations by IRS Watch for this MACA/MCHRMA 9/10/15 15

16 Form 1094-C, Part II, Line 22 Remember: Only completing if authoritative transmittal The Four Boxes Qualifying Offer Method Qualifying Offer Method Transition Relief Section 4980H Transition Relief 98% Offer method Employer determines whether apply and whether want to take advantage Check all that apply Important: Boxes checked significantly impact what needs to be completed and how. MACA/MCHRMA 9/10/15 16

17 1094-C Part II, Line 22, Box A checked yes If eligible to use and using qualifying offer method (QOM) for one or more full-time employees Described p.6 of 2015 draft instructions Qualifying offer defined pp of 2015 draft instructions Employer certification that made a qualifying offer (QO) to one or more full-time employees for all months during the calendar year in which employee was a full-time employee Not a month by month determination Code 1A in the all 12 months box Note: Rarely would all full-time employees have been made QO. MACA/MCHRMA 9/10/15 17

18 Offer of MEC providing minimum value to full-time employee to which penalty could apply (excludes those in LNP) for all months of the year, at a cost not greater than 9.5% of FPL divided by 12, and offer includes employee, dependents, and spouse. LNP defined on pp of 2015 draft instructions Must be minimum value All months Must be affordable under FPL threshold Must be offered to spouse MACA/MCHRMA 9/10/15 18

19 Must not complete 1095-C, Part II, Line 15 for any month in which QO made Where 1095-C, Part II, Line 14 indicates QO by using code 1A Not required Do not check 1094-C, Part II, Line 22, Box A Instead complete 1095-C, Part II, Lines 14 and 15 Some software systems do not use QOM MACA/MCHRMA 9/10/15 19

20 1094-C Part II, Line 22, Box B checked yes If eligible for and using qualifying offer method transitional relief (QOM-TR) for one or more full-time employees Described on p.7 of 2015 draft instructions Employer certification that made a QO for one or more months of the calendar year 2015 to at least 95% of fulltime employees (excludes those in LNP) QO offer of MEC providing minimum value to full-time employee to which penalty could apply (i.e., exclude LNP) for one or more months of the year, at a cost not greater than 9.5% of FPL divided by 12, and offer includes employee, dependents, and spouse. MACA/MCHRMA 9/10/15 20

21 Transitional because temporary 1095-C. Part II. Line 14, Code 1A for months employee received a QO 1095-C. Part II. Line 14, Code 1I for months employee did not receive a QO Must not complete 1095-C, Part II, Line 15 for any month in which QO made or QOM-TR applies Where 1095-C, Part II, Line 14 indicates 1A or 1I Not required Do not check 1094-C, Part II, Line 22, Box B Instead complete 1095-C, Part II, Lines 14 and 15 Note: Some software systems may not use QOM-TR. MACA/MCHRMA 9/10/15 21

22 1094-C Part II, Line 22, Box C checked yes Special penalty related rules Transition because not permanent ALEs with employees P.15 of 2015 draft instructions Look at documentation regarding ALE status If qualify, penalty assessable beginning 2016 ALE with 100 or more FTEs P.15 of 2015 draft instructions Penalty assessable beginning 2015 For 2015, minus 80 freebies instead of minus 30 freebies Note: Do not automatically get this relief. Must check the box! Must complete 1094-C, Part III, column (e) MACA/MCHRMA 9/10/15 22

23 ALE where offer made to at least 70% full-time employees PP draft instructions Penalty assessable beginning 2015 For 2015, 70 instead of 95% Non-calendar year plan year P.16 of 2015 draft instructions If qualify, penalty assessable essentially delayed to first day 2015 plan year Treat as offered MEC Part III, column (a) MACA/MCHRMA 9/10/15 23

24 Two groups of full-time employees Eligible for coverage Not eligible for coverage Eligible for coverage Eligible on first day 2015 plan year Under eligibility terms as existed Feb. 9, Treat as having offered coverage Part III, column (a) MACA/MCHRMA 9/10/15 24

25 Not eligible for coverage Significant percentage all employees Significant percentage full-time employees All employees offered no later than first day 2015 and At lease 25% employees enrolled in health coverage any day in the 12 months ending Feb. 9, 2014 or Offered coverage to at least 33 1/3 % during open enrollment that ended most recently before Feb. 9, 2014 Treat as having offered coverage Part III, column (a) MACA/MCHRMA 9/10/15 25

26 Full-time employees offered no later than first day of 2015 plan year and At least 33 1/3 % full-time employees enrolled in health coverage any day in the 12 months ending on Feb. 9, 2014 or Offered coverage to at least 50% full-time employees during open enrollment that ended most recently before Feb. 9, 2014 Treat as having offered coverage Part III, column (a) MACA/MCHRMA 9/10/15 26

27 1094-C Part II, Line 22, Box D checked yes If eligible for and using 98% offer for one or more full-time employees (see p.7 of 2015 draft instructions) Employer certification that offered for all months of calendar year affordable health coverage (under one of the safe harbors) providing minimum value to at least 98% of its employees (excluding those in LNP) for whom filing a C, and offered MEC to employees dependents. Not required to offer to spouse Not required to use FPL for affordability Not required to identify which employees Document analysis Do not have to complete 1094-C, Part III, column (b) Not required Do not check 1094-C, Part II, Line 22, Box D Instead complete 1095-C, Part II, Lines 14 and 15 and Part III, column (b) Note: Some software systems may not use 98% OM. MACA/MCHRMA 9/10/15 27

28 Column (a) Minimum Essential Coverage (MEC) Offer Indicator P.8 of 2015 draft instructions Check yes or no Where 1094-C Part II, Line 22, Box C checked yes Box C is Section 4980H Transitional Relief ALE with 100 or more employees (i.e., penalty assessable in 2015) For 2015, minus 80 freebies instead of minus 30 freebies Check yes MACA/MCHRMA 9/10/15 28

29 Non-calendar plan year If qualify for transitional relief (see description on p. 16 of 2015 draft Instructions) Months prior to start of plan year can check yes if offer health coverage no later than first day of 2015 plan year Relief: Get to check yes even though did not offer (i.e., effectively delays 2015 penalty assessment date) Line 23 if all information the same for all 12 months Or lines Complete month by month MACA/MCHRMA 9/10/15 29

30 Column (b) Full-time Employee Count P.8 of 2015 draft instructions If checked 1094-C, Line 22, Box D (98% Offer Method), do not complete Number of full-time employees for each calendar month minus full-time employees in a Limited Non-Assessment Period (LNP) NOT related to full-time employees that took coverage Used to calculate Penalty (a) LNP Recognized period during which not penalty assessable Examples include waiting period, first month of employment (see p.14 of 2015 draft instructions) MACA/MCHRMA 9/10/15 30

31 Use same day each month First day of calendar month Last day of calendar month First day of first payroll period in month Last day of first payroll period in month If the same number for each calendar month, may use all 12 months instead of month by month MACA/MCHRMA 9/10/15 31

32 Column (c) Total Employee Count P.8 of 2015 draft instructions Total number of employees for each calendar month Full-time, part-time, seasonal, temporary, LNP, etc. NOT related to those that took coverage Use same day each month Same method options as column (b) If the same number for each calendar month, may use all 12 months instead of month by month MACA/MCHRMA 9/10/15 32

33 Column (d) Aggregated Group Indicator P.8 of 2015 draft instructions Complete if checked yes on 1094-C, Part II, Line 21 Line 23 if all information the same for all 12 months Or lines Complete month by month If check any box yes, must complete C, Part IV MACA/MCHRMA 9/10/15 33

34 Column (e) Section 4980H Transitional Relief Indicator P.8 of 2015 draft instructions If checked yes on 1094-C, Part II, Line 22, Box D Availability of relief is employer responsibility to determine Code A if qualify for and are requesting relief (not penalty assessable in 2015) Code B if qualify for and are requesting 100 or more relief (penalty assessable but lower thresholds for 2015) Cannot be eligible for both MACA/MCHRMA 9/10/15 34

35 COMPLETE ONLY IF PART OF AGGREGATED ALE GROUP If checked yes on 1094-C, Part II, Line 21 Complete if part of aggregated ALE group at any time during calendar year List top 30 ALE members in descending order based on highest average full-time employees ALE member defined p.12 of 2015 draft instructions If entity in controlled group does not have employees, then not considered ALE member Must also complete 1094-C, Part III, column (d) MACA/MCHRMA 9/10/15 35

36 IRS Form 1095-C (2015) MACA/MCHRMA 9/10/15 36

37 One for each full-time employee Full-time under Health Care Reform Regardless of whether actually covered Full-time employee for any month of the calendar year If self-insured, also for each other employee (i.e., other than full-time) actually covered Because reporting as ALE and as provider If self-insured, also for any other person actually covered Alternatively, can use B series [more later] Lines 7 13 need to match Form 1094-C entries MACA/MCHRMA 9/10/15 37

38 Offer Provides employee an effective opportunity to enroll in MEC health coverage (or decline that coverage) at least once each plan year Offer to employee and dependents; offer to spouse not required Plan start month New Optional for 2015 Will be a two digit code in 2015 Instructions when issued MACA/MCHRMA 9/10/15 38

39 Line 14: Offer of Coverage Look at possibilities pp of 2015 draft instructions 1A if qualifying offer (MV and affordable under FPL safe harbor) Checked the box on 1094-C, Line 22 If MEC and MV to employee and at least MEC to dependents and spouse First column if all 12 months Otherwise, each calendar month NOT related to who actually takes coverage; just about the offer MACA/MCHRMA 9/10/15 39

40 Line 14 Example: FT employee hired on June 15, 2015; coverage available first of month following 30 days employment June July 1H for months prior to first coverage month August December 1E months offered Compare to employee covered for entire year all boxes would be 1E so use all 12 months MACA/MCHRMA 9/10/15 40

41 Line 15: Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage P.10 of 2015 draft instructions Affordability factor NOT related to what employee actually takes Only complete if line 14 is 1B, 1C, 1D, or 1E Leave blank if line 14 is 1A qualified offer If checked box on 1094-C, Line 22, Box A MACA/MCHRMA 9/10/15 41

42 Line 16: Applicable Section 4980H Safe Harbor Pp of 2015 draft instructions Note: if applicable Code 2 series Safe harbor codes and other relief Addresses which to use when more than one applies If none apply, leave blank First column if all 12 months Otherwise month by month MACA/MCHRMA 9/10/15 42

43 Common examples include 2C if enrolled in coverage each day of the month Overrides any other applicable code Remember: If enrolled, not subsidy eligible 2D if in LNP 2A if not an employee on any day of the month 2I if qualify for non-calendar transitional relief MACA/MCHRMA 9/10/15 43

44 Line 16 Example: FT employee hired on June 15, 2015; coverage available first of month following 30 days employment; employee actually enrolls Jan May June and July August Dec 2A 2D (LNP) 2C Compare to FT enrolled all year 2C MACA/MCHRMA 9/10/15 44

45 ONLY IF SELF INSURED Check the box! Report covered individuals Not employees Persons covered through employee Dependents Spouse Domestic partner MACA/MCHRMA 9/10/15 45

46 Persons not covered through employee P.11 of 2015 draft instructions Retiree (beginning year after) Former employee on COBRA (beginning year after) Other non-employee (e.g., independent contractor) For persons not covered through employee, may use 1095-B or 1095-C If use 1095-C, Part II, Line 14 coded 1G for all 12 months MACA/MCHRMA 9/10/15 46

47 Columns (b) and (c) Social Security Number 2 attempts to collect after first unsuccessful attempt (e.g., open enrollment) Birth date alternative if attempts to collect fail Document If all months the same, all 12 months Otherwise, month by month MACA/MCHRMA 9/10/15 47

48 Do a preliminary run through the documents now Penalties assessed monthly so may be time to fix going forward Make sure you qualify for simplified reporting (4 boxes) and other relief Identify To Do items regarding tracking, documentation, etc. Person listed as contact Person that signs Document determinations (e.g., ALE, qualify for transitional relief, etc.) Keep all information used to complete forms Information actually reported Information that supports how reported Information in case a mistake was made MACA/MCHRMA 9/10/15 48

49 49 MACA/MCHRMA 9/10/15 49

50 Caution: DRAFT NOT FOR FILING This is an early release draft of an IRS tax form, instructions, or publication, which the IRS is providing for your information as a courtesy. Do not file draft forms. Also, do not rely on draft instructions and publications for filing. We generally do not release drafts of forms until we believe we have incorporated all changes. However, unexpected issues sometimes arise, or legislation is passed, necessitating a change to a draft form. In addition, forms generally are subject to OMB approval before they can be officially released. Drafts of instructions and publications usually have at least some changes before being officially released. Early releases of draft forms and instructions are at IRS.gov/draftforms. Please note that drafts may remain on IRS.gov even after the final release is posted at IRS.gov/downloadforms, and thus may not be removed until there is a new draft for the subsequent revision. All information about all revisions of all forms, instructions, and publications is at IRS.gov/formspubs. Almost every form and publication also has its own easily accessible information page on IRS.gov. For example, the Form 1040 page is at IRS.gov/form1040; the Form W-2 page is at IRS.gov/w2; the Publication 17 page is at IRS.gov/pub17; the Form W-4 page is at IRS.gov/w4; the Form 8863 page is at IRS.gov/form8863; and the Schedule A (Form 1040) page is at IRS.gov/schedulea. If typing in the links above instead of clicking on them: type the link into the address bar of your browser, not in a Search box; the text after the slash must be lowercase; and your browser may require the link to begin with Note that these are shortcut links that will automatically go to the actual link for the page. If you wish, you can submit comments about draft or final forms, instructions, or publications on the Comment on Tax Forms and Publications page on IRS.gov. We cannot respond to all comments due to the high volume we receive, but we will carefully consider each one. Please note that we may not be able to consider many suggestions until the subsequent revision of the product.

51 Form1094-C Department of the Treasury Internal Revenue Service DRAFT AS OF June 16, 2015 DO NOT FILE Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Information about Form 1094-C and its separate instructions is at Part I Applicable Large Employer Member (ALE Member) 1 Name of ALE Member (Employer) 2 Employer identification number (EIN) 3 Street address (including room or suite no.) 4 City or town 5 State or province 6 Country and ZIP or foreign postal code 7 Name of person to contact 8 Contact telephone number 9 Name of Designated Government Entity (only if applicable) 10 Employer identification number (EIN) CORRECTED OMB No Street address (including room or suite no.) 12 City or town 13 State or province 14 Country and ZIP or foreign postal code For Official Use Only 15 Name of person to contact 16 Contact telephone number 17 Reserved Total number of Forms 1095-C submitted with this transmittal Is this the authoritative transmittal for this ALE Member? If Yes, check the box and continue. If No, see instructions Part II ALE Member Information 20 Total number of Forms 1095-C filed by and/or on behalf of ALE Member Is ALE Member a member of an Aggregated ALE Group? Yes No If No, do not complete Part IV. 22 Certifications of Eligibility (select all that apply): A. Qualifying Offer Method B. Qualifying Offer Method Transition Relief C. Section 4980H Transition Relief D. 98% Offer Method Under penalties of perjury, I declare that I have examined this return and accompanying documents, and to the best of my knowledge and belief, they are true, correct, and complete. Signature Title For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No A Form 1094-C (2015) Date

52 DRAFT AS OF June 16, Form 1094-C (2015) Page 2 Part III ALE Member Information Monthly 23 All 12 Months (a) Minimum Essential Coverage Offer Indicator Yes No (b) Full-Time Employee Count for ALE Member (c) Total Employee Count for ALE Member (d) Aggregated Group Indicator (e) Section 4980H Transition Relief Indicator 24 Jan 25 Feb DO NOT FILE 26 Mar 27 Apr 28 May 29 June 30 July 31 Aug 32 Sept 33 Oct 34 Nov 35 Dec Form 1094-C (2015)

53 DRAFT AS OF Enter the names and EINs of Other ALE Members of the Aggregated ALE Group (who were members at any time during the calendar year) Form 1094-C (2015) Page 3 Part IV Other ALE Members of Aggregated ALE Group 36 Name June 16, 2015 EIN 51 Name EIN DO NOT FILE Form 1094-C (2015)

54 Caution: DRAFT NOT FOR FILING This is an early release draft of an IRS tax form, instructions, or publication, which the IRS is providing for your information as a courtesy. Do not file draft forms. Also, do not rely on draft instructions and publications for filing. We generally do not release drafts of forms until we believe we have DRAFT AS OF August 6, 2015 DO NOT FILE incorporated all changes. However, unexpected issues sometimes arise, or legislation is passed, necessitating a change to a draft form. In addition, forms generally are subject to OMB approval before they can be officially released. Drafts of instructions and publications usually have at least some changes before being officially released. Early releases of draft forms and instructions are at IRS.gov/draftforms. Please note that drafts may remain on IRS.gov even after the final release is posted at IRS.gov/downloadforms, and thus may not be removed until there is a new draft for the subsequent revision. All information about all revisions of all forms, instructions, and publications is at IRS.gov/formspubs. Almost every form and publication also has its own easily accessible information page on IRS.gov. For example, the Form 1040 page is at IRS.gov/form1040; the Form W-2 page is at IRS.gov/w2; the Publication 17 page is at IRS.gov/pub17; the Form W-4 page is at IRS.gov/w4; the Form 8863 page is at IRS.gov/form8863; and the Schedule A (Form 1040) page is at IRS.gov/schedulea. If typing in the links above instead of clicking on them: type the link into the address bar of your browser, not in a Search box; the text after the slash must be lowercase; and your browser may require the link to begin with Note that these are shortcut links that will automatically go to the actual link for the page. If you wish, you can submit comments about draft or final forms, instructions, or publications on the Comment on Tax Forms and Publications page on IRS.gov. We cannot respond to all comments due to the high volume we receive, but we will carefully consider each one. Please note that we may not be able to consider many suggestions until the subsequent revision of the product.

55 Form 1095-C Department of the Treasury Internal Revenue Service Employer-Provided Health Insurance Offer and Coverage VOID CORRECTED Information about Form 1095-C and its separate instructions is at Part I Employee Applicable Large Employer Member (Employer) 1 Name of employee 2 Social security number (SSN) 7 Name of employer 8 Employer identification number (EIN) 3 Street address (including apartment no.) DRAFT AS OF August 6, 2015 DO NOT FILE 4 City or town 5 State or province 6 Country and ZIP or foreign postal code Part II 14 Offer of Coverage (enter required code) Employee Offer and Coverage OMB No Street address (including room or suite no.) 10 Contact telephone number 11 City or town 12 State or province 13 Country and ZIP or foreign postal code All 12 Months Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 15 Employee Share of Lowest Cost Monthly Premium, for Self-Only Minimum Value Coverage $ $ $ $ $ $ $ $ $ $ $ $ $ 16 Applicable Section 4980H Safe Harbor (enter code, if applicable) Part III Covered Individuals If Employer provided self-insured coverage, check the box and enter the information for each covered individual. (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months Plan Start Month (Enter 2-digit number): (e) Months of Coverage Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec For Privacy Act and Paperwork Reduction Act Notice, see separate instructions. Cat. No M Form 1095-C (2015)

56 Form 1095-C (2015) Page 2 Instructions for Recipient You are receiving this Form 1095-C because your employer is an Applicable Large Employer subject to the employer shared responsibility provision in the Affordable Care Act. This Form 1095-C includes information about the health insurance coverage offered to you by your employer. Form 1095-C, Part II, includes information about the coverage, if any, your employer offered to you and your spouse and dependent(s). If you purchased health insurance coverage through the Health Insurance Marketplace and wish to claim the premium tax credit, this information will assist you in determining whether you are eligible. For more information about the premium tax credit, see Pub. 974, Premium Tax Credit (PTC). You may receive multiple Forms 1095-C if you had multiple employers during the year that were Applicable Large Employers (for example, you left employment with one Applicable Large Employer and began a new position of employment with another Applicable Large Employer). In that situation, each Form 1095-C would have information only about the health insurance coverage offered to you by the employer identified on the form. If your employer is not an Applicable Large Employer it is not required to furnish you a Form 1095-C providing information about the health coverage it offered. DRAFT AS OF August 6, 2015 DO NOT FILE In addition, if you, or any other individual who is offered health coverage because of their relationship to you (referred to here as family members), enrolled in your employer's health plan and that plan is a type of plan referred to as a "self-insured" plan, Form 1095-C, Part III provides information to assist you in completing your income tax return by showing you or those family members had qualifying health coverage (referred to as "minimum essential coverage") for some or all months during the year. If your employer provided you or a family member health coverage through an insured health plan or in another manner, the issuer of the insurance or the sponsor of the plan providing the coverage will furnish you information about the coverage separately on Form 1095-B, Health Coverage. Similarly, if you or a family member obtained minimum essential coverage from another source, such as a government-sponsored program, an individual market plan, or miscellaneous coverage designated by the Department of Health and Human Services, the provider of that coverage will furnish you information about that coverage on Form 1095-B. If you or a family member enrolled in a qualified health plan through a Health Insurance Marketplace, the Health Insurance Marketplace will report information about that coverage on Form 1095-A, Health Insurance Marketplace Statement. Employers are required to furnish Form 1095-C only to the employee. As the recipient of this Form 1095-C, you should provide a copy to any family members TIP covered under a self-insured employer-sponsored plan listed in Part III if they request it for their records. Part I. Employee Lines 1 6. Part I, lines 1 6, reports information about you, the employee. Line 2. This is your social security number (SSN). For your protection, this form may show only the last four digits of your SSN. However, the issuer is required to report your complete SSN to the IRS. If you do not provide your SSN and the SSNs of all covered individuals to the plan administrator, the IRS may not be able to match the Form 1095-C to determine that! you and the other covered individuals have complied with the individual shared CAUTION responsibility provision. For covered individuals other than the employee listed in Part I, a Taxpayer Identification Number (TIN) may be provided instead of an SSN. Part I. Applicable Large Employer Member (Employer) Lines Part I, lines 7 13, reports information about your employer. Line 10. This line includes a telephone number for the person whom you may call if you have questions about the information reported on the form. Part II. Employer Offer and Coverage, Lines Line 14. The codes listed below for line 14 describe the coverage that your employer offered to you and your spouse and dependent(s), if any. This information relates to eligibility for coverage subsidized by the premium tax credit for you, your spouse, and dependent(s). For more information about the premium tax credit, see Pub A. Minimum essential coverage providing minimum value offered to you with an employee contribution for self-only coverage equal to or less than $1, (9.5% of the 48 contiguous states single federal poverty line) and minimum essential coverage offered to your spouse and dependent(s) (referred to here as a Qualifying Offer). This code may be used to report for specific months for which a Qualifying Offer was made, even if you did not receive a Qualifying Offer for all 12 months of the calendar year. 1B. Minimum essential coverage providing minimum value offered to you and minimum essential coverage NOT offered to your spouse or dependent(s). 1C. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) but NOT your spouse. 1D. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your spouse but NOT your dependent(s). 1E. Minimum essential coverage providing minimum value offered to you and minimum essential coverage offered to your dependent(s) and spouse. 1F. Minimum essential coverage NOT providing minimum value offered to you, or you and your spouse or dependent(s), or you, your spouse, and dependent(s). 1G. You were NOT a full-time employee for any month of the calendar year but were enrolled in self-insured employer-sponsored coverage for one or more months of the calendar year. This code will be entered in the All 12 Months box on line 14. 1H. No offer of coverage (you were NOT offered any health coverage or you were offered coverage that is NOT minimum essential coverage). 1I. Your employer claimed "Qualifying Offer Transition Relief" for 2015 and for at least one month of the year you (and your spouse or dependent(s)) did not receive a Qualifying Offer. Note that your employer has also provided a contact number at which you may request further information about the health coverage, if any, you were offered (see line 10). Line 15. This line reports the employee share of the lowest-cost monthly premium for self-only minimum essential coverage providing minimum value that your employer offered you. 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, or 1E 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. This code provides the IRS information to administer the employer shared responsibility provisions. None of this information affects your eligibility for the premium tax credit. For more information about the employer shared responsibility provisions, see IRS.gov. Part III. Covered Individuals, Lines Part III reports the name, SSN (or TIN for covered individuals other than the employee listed in Part I), and coverage information about each individual (including any full-time employee and non-full-time employee, and any employee's family members) covered under the employer's health plan, if the plan is "self-insured." A date of birth will be entered in column (c) only if an SSN (or TIN for covered individuals other than the employee listed in Part I) is not entered in column (b). Column (d) will be checked if the individual was covered for at least one day in every month of the year. For individuals who were covered for some but not all months, information will be entered in column (e) indicating the months for which these individuals were covered. If there are more than 6 covered individuals, see the additional covered individuals on Part III, Continuation Sheet(s).

57 Name of employee Social security number (SSN) Form 1095-C (2015) Page 3 Part III Covered Individuals Continuation Sheet (a) Name of covered individual(s) (b) SSN (c) DOB (If SSN is not available) (d) Covered all 12 months (e) Months of coverage DRAFT AS OF August 6, 2015 DO NOT FILE Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Form 1095-C (2015)