A Cheat Sheet for ACA Codes - Thread HCM

1 555 North Point Center East - Suite 150 - Alpharetta, GA 30022 main (678) 366-3447 email web A Cheat Sheet for ACA Codes The information contained in this document is intended as a guide and is not tax or legal advice. If you have questions, please contact your tax preparer or other trusted advisor when filing forms with the IRS. The Form Below is Form 1095-C from the IRS website. This guide will explain each piece of the form and help you determine the proper Codes for the fields in Part II. Shown below in blue, Parts I and III are comprised of lines 1-13 and 17-34, respectively.

2 These sections are easily enough, just employee information. Part I Shown below in orange, Part II is made up of lines 15-17. This section uses two sets of Codes released by the IRS to help employers have consistency when detailing the medical benefits they present to their employees. The Codes are used to describe various coverages, offers and other helpful explanations to avoid penalties each month for the employee on the form. 600117 VOIDCORRECTEDForm 1095-CDepartment of the Treasury Internal Revenue ServiceEmployer-Provided Health Insurance Offer and Coverage a Do not attach to your tax return.

3 Keep for your Go to for instructions and the latest No. 1545-22512017 Part IEmployee 1 Name of employee 2 Social security number (SSN)3 Street address (including apartment no.) 4 City or town5 State or province 6 Country and ZIP or foreign postal codeApplicable Large Employer Member (Employer) 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.) 10 Contact telephone number11 City or town12 State or province13 Country and ZIP or foreign postal codePart IIEmployee Offer of CoveragePlan Start Month (Enter 2-digit number):All 12 MonthsJanFebMarAprMayJuneJulyAugSeptOctN ovDec14 Offer of Coverage (enter required code)15 Employee Required Contribution (see instructions) $$$$$$$$$$$$$16 Section 4980H Safe harbor and Other Relief (enter code, if applicable)Part IIIC overed Individuals If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.

4 (a) Name of covered individual(s)(b) SSN or other TIN(c) DOB (If SSN or other TIN is not available)(d) Covered all 12 months(e) Months of Coverage JanMarAprMayJuneJulyAugSeptOctNovDec1718 19 Feb202122 For Privacy Act and Paperwork Reduction Act Notice, see separate No. 60705 MForm 1095-C (2017) 555 North Point Center East - Suite 150 - Alpharetta, GA 30022 main (678) 366-3447 email web Line 14 Code Series 1 This line indicates to the IRS whether or not an employee was offered coverage, what options in coverage they were given, and for which months those options were available.

5 Note, if at any given time in the year an employee is eligible for this coverage, each month needs to be completed regardless of whether or not the employee maintained eligibility or employment. Note: The IRS is only interested in the cost for employer-only coverage. Code Meaning Use it when 1A Indicates that the employer offered minimum essential coverage (MEC), with minimum value (MV), being less than or equal to of the single, continental federal poverty line, to the employee, spouse and dependents. MEC was offered to the employee, spouse and dependents with MV, and is considered affordable at the employee-only level.

6 1B Is the same as above except coverage was offered to the employee only. The MEC, MV coverage was offered but only for the employee, not spouse or dependents. 1C Same as 1A, except coverage is for employee and children. The MEC, MV coverage was offered but only for the employee and its children, not spouse. 1D Same as 1A, except coverage is for employee and spouse. The MEC, MV coverage was offered but only for the employee and its spouse, not children. 1E MEC/MV coverage is offered to the employee, and MEC coverage is offered for the spouse and children but is that coverage is not provided at MV.

7 Use like 1A, except if MV is not offered for spouse and dependents. 1F MEC is offered for employee and spouse and dependents but does not meet MV. Use when MEC does not meet the MV standards. 1G Self-insured coverage is offered to an employee who is never classified as full-time at any time in the year. Non-FT employee at any point in the year is offered self-insured plan and took that option in the given month. 1H Non-MEC coverage or no coverage at all was offered to the employee. The employee was either not hired, in a probationary period, was ineligible for coverage, or was terminated and offered COBRA.

8 Also use when coverage was offered but does not meet MEC standards or was not offered for a full month. 600117 VOIDCORRECTEDForm 1095-CDepartment of the Treasury Internal Revenue ServiceEmployer-Provided Health Insurance Offer and Coverage a Do not attach to your tax return. Keep for your Go to for instructions and the latest No. 1545-22512017 Part IEmployee 1 Name of employee 2 Social security number (SSN)3 Street address (including apartment no.) 4 City or town5 State or province 6 Country and ZIP or foreign postal codeApplicable Large Employer Member (Employer) 7 Name of employer 8 Employer identification number (EIN) 9 Street address (including room or suite no.)

9 10 Contact telephone number11 City or town12 State or province13 Country and ZIP or foreign postal codePart IIEmployee Offer of CoveragePlan Start Month (Enter 2-digit number):All 12 MonthsJanFebMarAprMayJuneJulyAugSeptOctN ovDec14 Offer of Coverage (enter required code)15 Employee Required Contribution (see instructions) $$$$$$$$$$$$$16 Section 4980H Safe harbor and Other Relief (enter code, if applicable)Part IIIC overed Individuals If Employer provided self-insured coverage, check the box and enter the information for each individual enrolled in coverage, including the employee.(a) Name of covered individual(s)(b) SSN or other TIN(c) DOB (If SSN or other TIN is not available)(d) Covered all 12 months(e) Months of Coverage JanMarAprMayJuneJulyAugSeptOctNovDec1718 19 Feb202122 For Privacy Act and Paperwork Reduction Act Notice, see separate No.

10 60705 MForm 1095-C (2017) 555 North Point Center East - Suite 150 - Alpharetta, GA 30022 main (678) 366-3447 email web Guide for Code Series 1 555 North Point Center East - Suite 150 - Alpharetta, GA 30022 main (678) 366-3447 email web Line 15 - Is used as a cost indicator for coverage offered. Line 16 Code Series 2 This line s Codes are used to notate if the individual was employed and if that employment was full-time or part-time, if the employee took advantage of coverage, and if that coverage was affordable in connection with IRS safe harbor , and finally, if that employee was eligible for transition relief.