Contents of the 1095-Cs Screen

Download

When you click the Download button, the screen will display the Download and E-mail 1095-C Form where you can select the year and options for the 1095-C that you want to view, download, or email.

Note: The download and e-mail buttons on this form will be enabled only if your Benefits administrator enables this functionality.

Field	Description
Calendar Year	From the drop-down list, select the year of the 1095-C that you want to view. The list will contain the last 4 years including the current system year. Example: If Current System Year is 2023: The Calendar Year on the drop-down: 2020, 2021, 2022, and 2023. If Current System Year is 2024: The Calendar Year on the drop-down: 2021, 2022, 2023, and 2024. The default value is based on the calendar year of the current selected record.
Download	Select this option if you want to download the PDF file of your 1095-C.
E-mail	Select this option if you want to send the PDF file of your 1095-C to the address specified in the E-mail Address field.
Download and E-mail	Select this option if you want download and email the PDF file of your 1095-C. The file will be sent to the address specified in the E-mail Address field.
E-mail Address	Enter the email address to which the 1095-C form will be sent as a PDF file attachment. The default value of this field will be your work email or home email, and this will only be enabled if E-mail or Download and E-mail option is selected. Email can also be sent to multiple email address by using a semicolon as separator.
Submit	Click this button to email and/or download Form 1095-C as a PDF file.

Field	Description
Employee	This field displays your name.
Calendar Year	This field displays the 4-digit calendar year of the selected 1095-C.
Void	This checkbox indicates if the 1095-C record was voided.
Corrected	This checkbox indicates if the 1095-C record was corrected. If correcting information on a Form 1095-C that was previously filed with the IRS, file a fully completed Form 1095-C including the correct information and enter an X in the CORRECTED checkbox. File a Form 1094-C Transmittal (DO NOT mark the CORRECTED checkbox on the Form 1094-C) with corrected Form(s) 1095-C. Furnish the employee a copy of the corrected Form 1095-C, unless the employer is eligible to use the Qualifying Offer Method or the Qualifying Offer Method Transition Relief for 2015. For more information, see Alternative Method of Furnishing Form 1095-C to Employees under the Qualifying Offer Method or Alternative Method of Furnishing Form 1095-C to Employees under the Qualifying Offer Method Transition Relief.

Part I

This group box contains employee and applicable large employer member information.

Employee

Field	Description
1 Name of Employee	This field displays the name of the employee for which the 1095-C record is being entered.
2 Social Security Number	This field displays the Social Security Number (SSN) of the employee for which the 1095-C record is being entered.
3 Street Address (including apt number)	This field displays the street address (including apartment number) of the employee for which the 1095-C record is being entered.
4 City or Town	This field displays the city or town of the employee for which the 1095-C record is being entered.
5 State/Province	This field displays the State/Province of the employee for which the 1095-C record is being entered.
6 Country and ZIP or Foreign Postal Code	This field displays the Country and Postal Code of the employee for which the 1095-C record is being entered.

Applicable Large Employer Member (Employer)

Field	Description
7 Name of Employer	This field displays the name of the employer for which the 1095-C record is being entered.
8 Employer Identification Number	This field displays the Employer Identification Number (EIN) of the employer for which the 1095-C record is being entered.
9 Street Address (including room or suite number)	This field displays the Street Address (including room or suite number) of the employer for which the 1095-C record is being entered.
10 Contact Telephone Number	Enter the Contact Telephone Number of the taxable entity for which the 1095-C record is being entered.
11 City or Town	This field displays the city or town of the taxable entity for which the 1095-C record is being entered.
12 State/Province	This field displays the state/province of the taxable entity for which the 1095-C record is being entered.
13 Country and ZIP or Foreign Postal Code	This field displays the country and ZIP or foreign postal code of the taxable entity for which the 1095-C record is being entered.

Part II - Employee Offer and Coverage

Field	Description
Employee's Age on January 1	This field displays the age of the employee as of January 1st of the filing year.
Plan Start Month (Two-Digit Number)	This field displays the beginning month of the plan year of the health plan in which is the employee is offered coverage. This may also be the month that the employee would be offered coverage if the employee were eligible to participate in the plan.

14 Offer of Coverage

These fields display offer of coverage that applies all 12 months of the calendar year; or the offer of coverage that applies to each month. As of 2020, the list of valid Offer of Coverage codes are as follows:

1A: Qualifying Offer: Minimum essential coverage providing minimum value offered to full-time employee with Employee Required Contribution equal to or less than 9.5% (as adjusted) of mainland single federal poverty line and at least minimum essential coverage offered to spouse and dependent(s).
1B: Minimum essential coverage providing minimum value offered to employee only.
1C: Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to dependent(s) (not spouse).
1D: Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to spouse (not dependent(s)). Do not use code 1D if the coverage for the spouse was offered conditionally. Instead use code 1J.
1E: Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage offered to dependent(s) and spouse. Do not use code 1E if the coverage for the spouse was offered conditionally. Instead use code 1K.
1F: Minimum essential coverage NOT providing minimum value offered to employee; employee and spouse or dependent(s); or employee, spouse and dependents.
1G: Offer of coverage for at least one month of the calendar year to an individual who was not an employee for any month of the calendar year or to an employee who was not a full-time employee for any month of the calendar year (which may include one or more months in which the individual was not an employee) and who enrolled in self-insured coverage for one or more months of the calendar year.
Code 1G applies for the entire year or not at all. Therefore, if code 1G applies, an ALE Member must enter code 1G on line 14 in the All 12 Months field or in each separate monthly field (for all 12 months).
1H: No offer of coverage (employee not offered any health coverage or employee offered coverage that is not minimum essential coverage, which may include one or more months in which the individual was not an employee).
1I: Reserved.
1J: Minimum essential coverage providing minimum value offered to employee and at least minimum essential coverage conditionally offered to spouse; minimum essential coverage not offered to dependent(s).
1K: Minimum essential coverage providing minimum value offered to employee; at least minimum essential coverage offered to dependents; and at least minimum essential coverage conditionally offered to spouse.
1L: Individual coverage health reimbursement arrangement (HRA) offered to you only with affordability determined by using employee's primary residence location ZIP Code.
1M: Individual coverage HRA offered to you and dependent(s) (not spouse) with affordability determined by using employee's primary residence location ZIP Code.
1N: Individual coverage HRA offered to you, spouse and dependent(s) with affordability determined by using employee's primary residence location ZIP Code.
1O: Individual coverage HRA offered to you only using the employee's primary employment site ZIP Code affordability safe harbor.
1P: Individual coverage HRA offered to you and dependent(s) (not spouse) using the employee's primary employment site ZIP Code affordability safe harbor.
1Q: Individual coverage HRA offered to you, spouse and dependent(s) using the employee's primary employment site ZIP Code affordability safe harbor.
1R: Individual coverage HRA that is NOT affordable offered to you; employee and spouse or dependent(s); or employee, spouse, and dependents.
1S: Individual coverage HRA offered to an individual who was not a full-time employee.
1T: Individual coverage HRA offered to employee and spouse (no dependents) with affordability determined using employee's primary residence location ZIP code.
1U: Individual coverage HRA offered to employee and spouse (no dependents) using employee's primary employment site ZIP code affordability safe harbor.
1V: Reserved for future use.
1W: Reserved for future use.
1X: Reserved for future use.
1Y: Reserved for future use.
1Z: Reserved for future use.

Note: New codes 1J and 1K address conditional offers of spousal coverage (also referred to as coverage offered conditionally). A conditional offer is an offer of coverage that is subject to one or more reasonable, objective conditions (for example, an offer to cover an employee’s spouse only if the spouse is not eligible for coverage under Medicare or a group health plan sponsored by another employer). Using new codes 1J and 1K, an ALE Member may report a conditional offer to a spouse as an offer of coverage, regardless of whether the spouse meets the reasonable, objective condition. A conditional offer generally would impact a spouse’s eligibility for the premium tax credit under section 36B only if all conditions to the offer are satisfied (that is, the spouse was actually offered the coverage and eligible for it).

To help employees (and spouses) who have received a conditional offer determine their eligibility for the premium tax credit, the ALE Member should be prepared to provide, upon request, a list of any and all conditions applicable to the spousal offer of coverage. As is noted in the definition of dependent in the Definitions section, a spouse is not a dependent for purposes of section 4980H. An ALE Member may not report a conditional offer of coverage to an employee’s dependents as an offer to the dependents, unless the ALE Member knows that the dependents met the condition to be eligible for the ALE Member’s coverage. Further, an offer of coverage is treated as made to an employee’s dependents only if the offer of coverage is made to an unlimited number of dependents regardless of the actual number of dependents, if any, an employee has during any particular calendar month

This field must only be populated if the same Offer of Coverage code applies to the employee for the entire calendar year. If more than one code applies during the calendar year, leave this field blank.

Field	Description
Offer of Coverage - All 12 Months	If the same Offer of Coverage code applies to the employee for all 12 months of the screen calendar year, this field displays the Offer of Coverage code which applies to the employee.
Offer of Coverage - Jan - Dec	If the same Offer of Coverage code does not apply to every month in the year, these fields display the Offer of Coverage code which applies to the specific month.

15 Employee Required Contribution

These fields display the Employee Required Contribution amount that applies to all months of the calendar year. If the value does not apply to all months of the calendar year, the fields the corresponding value for specific months.

For an individual coverage HRA, the employee required contribution is the excess of the monthly premium based on the employee's applicable age for the applicable lowest cost silver plan over the monthly individual coverage HRA amount (generally, the annual individual coverage HRA amount divided by 12).

Field	Description
All 12 Months	If the Offer of Coverage is 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, IT, or 1U for all 12 months and the same employee required contribution applies to all 12 months of the screen calendar year, the amount is displayed in this field. This field must only be populated if the same employee required contribution applies to the employee for the entire calendar year.
Jan - Dec Fields	If the same Employee Share of Lowest Cost Monthly Premium does not apply to every month in the year, these fields display the corresponding amount that applies to the specific month. This field must only be populated if the same Employee Share of Lowest Cost Monthly Premium amount does not apply to the employee for the entire calendar year.

Field

Description

All 12 Months

If the Offer of Coverage is 1B, 1C, 1D, 1E, 1J, 1K, 1L, 1M, 1N, 1O, 1P, 1Q, IT, or 1U for all 12 months and the same employee required contribution applies to all 12 months of the screen calendar year, the amount is displayed in this field.

This field must only be populated if the same employee required contribution applies to the employee for the entire calendar year.

Jan - Dec Fields

If the same Employee Share of Lowest Cost Monthly Premium does not apply to every month in the year, these fields display the corresponding amount that applies to the specific month.

This field must only be populated if the same Employee Share of Lowest Cost Monthly Premium amount does not apply to the employee for the entire calendar year.

16 Section 4980H Safe Harbor & Other Relief

These fields display Section 4980H Safe Harbor code that applies to all months of the calendar year. If the codes are not the same for the whole calendar year, the corresponding Section 4980H Safe Harbor code is displayed in the fields for each month.

Valid Section 4980H Safe Harbor codes are as follows:

2A: Employee is not employed during the month. Enter code 2A if the employee was not employed on any day of the calendar month. Do not use code 2A for a month if the individual was an employee of the ALE Member on any day of the calendar month. Do not use code 2A for the month during which an employee terminates employment with the ALE Member.
2B: Employee is not a full-time employee. Enter code 2B if the employee is not a full-time employee for the month and did not enroll in minimum essential coverage, if offered for the month. Enter code 2B also if the employee is a full-time employee for the month and whose offer of coverage (or coverage if the employee was enrolled) ended before the last day of the month solely because the employee terminated employment during the month (so that the offer of coverage or coverage would have continued if the employee had not terminated employment during the month).
2C: Employee is enrolled in health coverage offered. Enter code 2C for any month in which the employee enrolled for each day of the month in health coverage offered by the ALE Member, regardless of whether any other code in Code Series 2 might also apply (for example, the code for a section 4980H affordability safe harbor) except as provided below. Do not enter code 2C in line 16 for any month in which the multiemployer interim rule relief applies (enter code 2E). Do not enter code 2C in line 16 if code 1G is entered in line 14. Do not enter code 2C in line 16 for any month in which a terminated employee is enrolled in COBRA continuation coverage or other post-employment coverage (enter code 2A). Do not enter code 2C in line 16 for any month in which the employee enrolled in coverage that was not minimum essential coverage.
2D: Employee is in a section 4980H(b) Limited Non-Assessment Period. Enter code 2D for any month during which an employee is in a section 4980H(b) Limited Non-Assessment Period. If an employee is in an initial measurement period, enter code 2D (employee in a section 4980H(b) Limited Non-Assessment Period) for the month, and not code 2B (employee not a full-time employee). For an employee in a section 4980H(b) Limited Non-Assessment Period for whom the ALE Member is also eligible for the multiemployer interim rule relief for the month, enter code 2E (multiemployer interim rule relief) and not code 2D (employee in a section 4980H(b) Limited Non-Assessment Period).
2E: Multiemployer interim rule relief. Enter code 2E for any month for which the multiemployer arrangement interim guidance applies for that employee, regardless of whether any other code in Code Series 2 (including code 2C) might also apply. This relief is described under Offer of Health Coverage in the Definitions section of these instructions.
Although ALE Members may use the section 4980H affordability safe harbors to determine affordability for purposes of the multiemployer arrangement interim guidance, an ALE Member eligible for the relief provided in the multiemployer arrangement interim guidance for a month for an employee should enter code 2E (multiemployer interim rule relief), and not codes 2F, 2G, or 2H (codes for section 4980H affordability safe harbors).
2F: Section 4980H affordability Form W-2 safe harbor. Enter code 2F if the ALE Member used the section 4980H Form W-2 safe harbor to determine affordability for purposes of section 4980H(b) for this employee for the year. If an ALE Member uses this safe harbor for an employee, it must be used for all months of the calendar year for which the employee is offered health coverage.
2G: Section 4980H affordability federal poverty line safe harbor. Enter code 2G if the ALE Member used the section 4980H federal poverty line safe harbor to determine affordability for purposes of section 4980H(b) for this employee for any month(s).
2H: Section 4980H affordability rate of pay safe harbor. Enter code 2H if the ALE Member used the section 4980H rate of pay safe harbor to determine affordability for purposes of section 4980H(b) for this employee for any month(s).
An affordability safe harbor code should not be entered on line 16 for any month that the ALE member did not offer minimum essential coverage to at least 95% of its full-time employees and their dependents (that is, any month for which the ALE member checked the “No” box on Form 1094-C, Part III, column (a)). For more information, see the instructions for Form 1094-C, Part III, column (a).
2I: Reserved.

Field	Description
Section 4980H Safe Harbor - All 12 Months	If the same Section 4980H Safe Harbor code applies to the employee for all 12 months of the screen calendar year, this field displays the Section 4980H Safe Harbor code which applies to you.
Section 4980H Safe Harbor - Jan - Dec Fields	If the same Section 4980H Safe Harbor code does not apply to every month in the year, these fields display your Section 4980H Safe Harbor code for each specific month.

17 ZIP Code

If you were offered an individual coverage health-reimbursement arrangement, this field displays the applicable ZIP code that your employer used for determining affordability.

If Code 1L, 1M, 1N, or 1T were used on Line 14, this will be the employee's primary residence location.

If Code 1O, 1P, 1Q, or 1U were used on Line 14, this will be the employee's primary work location.

Field	Description
ZIP Code - All 12 Months	This field displays ZIP code that your employer used for determining affordability, if the same ZIP code applies to the employee for the entire calendar year.
ZIP Code - Jan - Dec	This field displays the ZIP code that your employer used for determining affordability, if the same ZIP code does not apply to the employee for the entire calendar year.

Subtask

Subtask	Description
Part III - Covered Individuals	Select this link to enter Covered Individuals information.

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