Form 1095-A, Health Insurance Marketplace Statement Instructions

Enter the sum of the amounts from Part III – Coverage Information, column A: Monthly enrollment premiums for January through December. Enter in dollars and cents without a currency symbol (for example, 12345.67).

Enter the sum of all Part III, column B entries (Monthly second lowest cost silver plan (SLCSP) premium) for January through December. Enter the total in U.S. dollars and cents, using digits and a decimal point with exactly two decimal places (for example, 1234.56). Even if the total is zero, enter “0.00.”

Enter the total annual advance payment of premium tax credit (APTC) by summing the monthly APTC amounts reported in Part III, column C (lines 21–32). Enter the result as a whole‐dollar amount without dollar signs or commas.

Enter the total enrollment premium amount for April in Part III, Column A: Monthly enrollment premiums. If you had no coverage in April, enter 0. Use whole-dollar amounts only, omitting dollar signs and commas.

Enter the Marketplace-determined second lowest cost silver plan (SLCSP) premium for April. Provide the dollar amount in dollars and cents (for example, 1234.56), omitting the dollar sign and commas. If no premium applies for April, enter 0.00.

Enter the dollar amount of the advance payment of premium tax credit applied on your behalf for April as reported in Part III, column C. Required entry (enter 0.00 if none). Format as a numeric value with two decimal places (for example, 123.45), without a currency symbol.

Under “A. Monthly enrollment premiums,” enter the total dollar amount of the enrollment premium for August. If no coverage or no premium applies in August, enter 0.00. Do not include a dollar sign or commas; use digits only with two decimal places (for example, 1234.56).

Enter the dollar amount of the monthly second lowest cost silver plan (SLCSP) premium as determined by the Marketplace for August. Provide the figure in dollars and cents (two decimal places) without a dollar sign or commas (for example, 1234.56). If no premium applies for August, enter 0.00.

Enter the dollar amount of the monthly advance payment of premium tax credit applied on your behalf for coverage in August in Part III – Coverage Information, column C. Monthly advance payment of premium tax credit. If no advance payment was made for August, enter 0.00. Format as U.S. dollars and cents without a dollar sign (e.g., 1234.56).

Enter the full legal name of the first individual covered by the policy in Part II – Covered Individuals, column A. Include first name, middle initial (if applicable), and last name exactly as shown on your Marketplace statement. This field is required for the first covered individual.

Enter the first covered individual’s nine-digit Social Security Number in the format XXX-XX-XXXX. If no SSN is available, leave this field blank and enter the date of birth in Covered individual date of birth.

Enter the first covered individual’s date of birth in MM/DD/YYYY format. Complete this field only if no value is entered in B. Covered individual SSN; otherwise leave it blank.

Enter the coverage start date for the first covered individual listed in Covered Individuals. Use MM/DD/YYYY format.

Enter the date the first covered individual’s health insurance coverage ended during 2023 in MM/DD/YYYY format. Required only if coverage terminated before December 31, 2023; otherwise, leave this field blank.

What to enter: Full legal name (first name, middle initial or full middle name if used, and last name) of the second individual covered under this policy. When to enter: Complete only if there is a second covered individual; otherwise leave blank. How to format: Do not include prefixes (Mr., Ms., Dr.) or suffixes (Jr., Sr.).

Enter the nine-digit Social Security Number of the second covered individual listed under Part II Covered Individuals. Use only numeric digits without hyphens. If the individual does not have an SSN, leave this field blank and complete Covered individual date of birth instead.

Enter the date of birth of the second covered individual in MM/DD/YYYY format. Only complete this if no SSN is entered in Column B, Covered individual SSN; leave blank if an SSN is provided.

Enter the date when health coverage began for the second covered individual listed in Part II – Covered Individuals. Provide the month, day, and four-digit year in MM/DD/YYYY format. This field is required for every individual you list in Part II.

Enter the date (in MM/DD/YYYY format) when the second covered individual’s health coverage under this policy ended. If coverage continued through December 31, 2023, enter 12/31/2023.

If there is a third individual covered under the policy (Part II – Covered Individuals), enter that person’s full legal name (first name, middle initial if any, and last name). Leave blank if there is no third covered individual.

Enter the nine-digit Social Security number of the third covered individual listed in Part II. Enter all nine digits without dashes. If the covered individual does not have an SSN, leave this field blank and complete Covered individual date of birth instead.

Enter the date of birth for the third covered individual in MM/DD/YYYY format. Complete this field only if you are reporting a third covered individual in Part II – Covered Individuals; otherwise leave it blank.

Enter the coverage start date for the third covered individual listed in Part II – Covered Individuals, column D (“Coverage start date”). Use MM/DD/YYYY format. Complete only if you are reporting a third covered individual; otherwise leave blank.

Enter the date the third covered individual’s health coverage ended in 2023, using MM/DD/YYYY format. If that individual remained covered through December 31, 2023, leave this field blank.

Enter the full legal name (first name, middle initial if any, last name) of the fourth individual covered under your Marketplace health plan in Part II, under the header “A. Covered individual name.” Complete this field only if a fourth person is covered; otherwise leave it blank.

Enter the nine-digit Social Security Number for the fourth covered individual listed in Part II. Do not include hyphens. If the individual does not have an SSN, leave this field blank and instead complete the “Covered individual date of birth” field.

Enter the date of birth of the fourth covered individual in MM/DD/YYYY format. Only complete this field if no Social Security number is entered in Covered individual SSN for the fourth covered individual; if a Social Security number is entered there, leave this field blank.

Enter the coverage start date for the fourth covered individual listed in Part II – Covered Individuals. Use MM/DD/YYYY format. Required for each covered individual.

Enter the coverage termination date for the fourth individual listed in Part II. If coverage ended before December 31, 2023, enter the date in MM/DD/YYYY format. Leave blank if coverage continued through December 31, 2023.

Enter the full legal name (first name, middle initial if any, and last name) of the fifth individual covered under the policy as reported in Part II under “A. Covered individual name.” If there is no fifth covered individual, leave this field blank.

Enter the 9-digit Social Security Number for the fifth covered individual in Part II, Covered Individuals. If the individual does not have an SSN, leave this field blank and complete C. Covered individual date of birth instead. Enter digits only, without spaces or hyphens.

Enter the date of birth for the fifth covered individual if no Social Security number is entered in the “Covered individual SSN” field. Use MM/DD/YYYY format.

Enter the date coverage began for the fifth covered individual listed in Part II – Covered Individuals. Provide the date in MM/DD/YYYY format (e.g., 01/31/2023). Complete this field only if you are reporting a fifth covered individual; otherwise leave it blank.

Enter the date coverage ended for the fifth covered individual in MM/DD/YYYY format. If coverage continued through December 31, 2023, leave this field blank.

Enter the December amount for "A. Monthly enrollment premiums" in dollars and cents (for example, 1234.56). If no premium was due or paid for December, enter 0.00.

Enter the December monthly second lowest cost silver plan (SLCSP) premium amount as determined by the Marketplace. Provide the dollar amount without a dollar sign or commas, using two decimal places (for example, 123.45).

Enter the amount of the advance payment of premium tax credit applied on your behalf for December. Include dollars and cents (for example, 1234.56). If no advance credit was applied in December, enter 0.00.

Enter the total Marketplace enrollment premium for February in dollars and cents. Use only numeric digits, without a dollar sign or commas (for example, 123.45). If no coverage existed in February, enter 0.00.

Enter the Marketplace-determined second lowest cost silver plan premium for February in dollars and cents (for example, 123.45). If no SLCSP premium applies for February, enter 0.00.

Enter the advance payment of premium tax credit applied on your behalf by the Marketplace for coverage in February 2023. Provide the amount in dollars and cents (e.g., 123.45). If no advance payment was made, enter 0.00.

Check this box when the Marketplace issued the form in error to indicate it should not be used for reporting coverage or reconciling premium tax credits.

Check this box when the Marketplace is issuing this Form 1095-A as a corrected version to replace an earlier statement.

Enter the total enrollment premium for January as reported in Part III, column A (Monthly enrollment premiums). Include the full premium amount (your share plus any advance payment of the premium tax credit, reduced for non-essential benefits). Enter the amount in U.S. dollars and cents; omit the dollar sign and commas, and use a period for the decimal point (for example, 1234.56).

Enter the January premium amount from Part III under “B. Monthly second lowest cost silver plan (SLCSP) premium.” Provide the value in US dollars and cents with two decimal places (for example, 1234.56), omitting dollar signs and commas. Leave blank if you did not have coverage in January.

Enter the dollar amount of your January 2023 monthly advance payment of the Premium Tax Credit paid on your behalf by the Marketplace (Part III, column C). Use whole dollars only; do not include cents, dollar signs, or commas. If no advance payment was made for January, enter 0.

Enter the total enrollment premium amount for July in column A (Monthly enrollment premiums). Include both the amount you paid and any advance payment of the premium tax credit applied on your behalf. Enter the value in dollars and cents (for example, 123.45). If you had no coverage in July, enter 0.00.

Enter the Marketplace-determined second lowest cost silver plan premium for July in U.S. dollars and cents (for example, 123.45). This corresponds to Part III – Coverage Information, column B. Monthly second lowest cost silver plan (SLCSP) premium. If no SLCSP premium applies for July, enter 0.00.

In Part III Coverage Information, under C. Monthly advance payment of premium tax credit, enter the total advance premium tax credit applied on your behalf for July 2023. If no advance payment was applied for July, enter 0. Format as a dollar amount with two decimal places (e.g., 1234.56).

Enter the total enrollment premium amount for June as reported in Part III, column A (“Monthly enrollment premiums”). Include the full premium (your share plus any advance payment of premium tax credit), reduced for any non-essential health benefits. Enter the amount in dollars and cents (for example, 1234.56). If you had no coverage in June, enter 0.

Enter the monthly second lowest cost silver plan (SLCSP) premium amount determined by the Marketplace for June. Provide this as a dollar value including cents (for example, 250.00). Leave the field blank if no SLCSP was determined for June.

Enter the total advance payment of premium tax credit applied on your behalf for June 2023. Use Column C: Monthly advance payment of premium tax credit and enter the amount in dollars and cents without a dollar sign (e.g., 123.45). If no advance payment was made for June, enter 0.00.

Enter in A. Monthly enrollment premiums the total enrollment premium amount for March, including amounts you paid plus any advance payment of the premium tax credit (reduced for non-essential benefits). Enter in dollars and cents, omitting the dollar sign and commas, with two decimal places (for example, 1234.56). If no premium applies for March, enter 0.00.

Enter the Marketplace-determined Monthly second lowest cost silver plan (SLCSP) premium for March in dollars and cents. If no SLCSP premium was determined for March, enter 0. Do not include a currency symbol or commas (e.g., 1234.56).

Enter the dollar amount of the advance payment of premium tax credit applied to your health insurance premiums for March under “C. Monthly advance payment of premium tax credit.” Use dollars and cents, omitting the dollar sign and commas (for example, 123.45). If no advance credit was applied for March, enter 0.00.

Enter the total enrollment premium for May from Part III, A. Monthly enrollment premiums. Use numeric format in dollars and cents without currency symbols or commas (e.g., 1234.56). Required; if no coverage in May, enter 0.00.

Enter the dollar amount of the Monthly second lowest cost silver plan (SLCSP) premium for May in Part III – Coverage Information, column B. Use two decimal places (for example, 150.00). If no SLCSP premium applies for May, enter 0.00.

Enter in U.S. dollars and cents (no dollar sign or commas) the amount reported in Part III, Column C (“Monthly advance payment of premium tax credit”) for May. If you did not receive an advance payment of the premium tax credit for May, enter 0.00.

Enter the total enrollment premium for November in U.S. dollars and cents (for example, 1234.56). Include cents with a decimal point. If no premium applies for November, enter 0.00.

Enter the Part III, column B (Monthly second lowest cost silver plan (SLCSP) premium) amount for November. Input the premium in dollars and cents (e.g., 123.45) using numbers only, without dollar signs or commas. This field is required.

Enter the monthly advance payment of premium tax credit applied on your behalf for November in US dollars and cents, without dollar signs or commas (for example, 1234.56). If no advance payment was made in November, enter 0.00.

Enter the total enrollment premium for October 2023, including both the amount you paid and any advance payment of the premium tax credit. Provide the amount in U.S. dollars and cents with two decimal places (for example, 1234.56). Do not include a dollar sign or commas. If you had no coverage in October, enter 0.

Enter the October amount of the Monthly second lowest cost silver plan (SLCSP) premium from Part III, Column B. Provide the dollar and cents value (for example, 1234.56). If no premium applies for October, enter 0.00.

Enter the amount of advance payment of premium tax credit applied to your coverage for October 2023. Use dollars and cents, without the “$” symbol, and include two decimal places (for example, 1234.56). Enter 0.00 if no advance payment was received for October.

Enter the Marketplace identifier code assigned by your Health Insurance Marketplace, exactly as shown in your Marketplace notice. For state Marketplaces, use the two-letter postal abbreviation (for example, CA or NY); for the federal Marketplace, enter the specific code provided. This field is required.

Enter the unique alphanumeric code your Health Insurance Marketplace assigned to this policy. This field is required. Type the full code exactly as shown, including all letters, numbers, and any hyphens or other characters.

Enter the full legal name of the insurance company that issued your Marketplace health plan, exactly as it appears on your plan documents (including any suffixes such as “Inc.” or “LLC”). This field is required to ensure the issuer name matches official IRS reporting records.

Enter the primary recipient’s full legal name exactly as it appears on your Health Insurance Marketplace enrollment record. Include first name, middle initial (if any), and last name. This field is required.

Enter the recipient’s nine-digit Social Security Number in the format XXX-XX-XXXX. If the recipient does not have an SSN, leave this field blank and complete the Recipient’s date of birth field instead.

Enter the recipient’s date of birth using two digits for the month, two digits for the day, and four digits for the year (MM/DD/YYYY). Complete this field only if no entry is provided in Recipient’s SSN.

Enter the spouse’s full legal name using the same format as Recipient’s name: first name, middle initial (if applicable), and last name. Complete this field only if your spouse was covered by the Health Insurance Marketplace policy in 2023; otherwise leave it blank.

Enter the recipient’s spouse’s nine-digit Social Security number if advance payment of the premium tax credit was made and you provided a value in Recipient’s spouse’s name. Enter all nine digits without hyphens or spaces.

Enter your spouse’s date of birth in two-digit month, two-digit day, and four-digit year format (MM/DD/YYYY). This field is required only if you did not provide a Social Security Number for your spouse in Recipient’s spouse’s SSN. Leave blank if you have entered a valid SSN.

Enter the date your health insurance policy began coverage. Required. Use MM/DD/YYYY format (for example, 01/01/2023).

Enter the date your health insurance policy ended in MM/DD/YYYY format. If coverage continued through December 31, leave this field blank.

Enter the recipient’s full street address, including any apartment, suite, or unit number. Always complete this field. Include the street number and street name plus apartment or unit designator (for example, “123 Main St Apt 4B”). Do not enter city, state, or ZIP/postal code here.

Enter the city or town for the recipient’s address as shown in the “Street address (including apartment no.)” field. Required. Type the full city or town name (for example, Seattle), without including the state or ZIP code.

Enter the U.S. state or foreign province for the recipient’s mailing address. For U.S. addresses, use the two-letter U.S. Postal Service abbreviation (for example, CA for California). For addresses outside the United States, enter the full name of the province, territory, or foreign administrative region. This field is required.

Enter your mailing address ZIP code or foreign postal code and country: for U.S. addresses, enter a 5-digit ZIP code or ZIP+4 (e.g., 12345 or 12345-6789). For non-U.S. addresses, enter the foreign postal code followed by the country name (e.g., “M5G 2C3 Canada”).

Enter the total enrollment premium amount for September in the “A. Monthly enrollment premiums” column of Part III. Provide the dollar amount in U.S. format with dollars and cents (e.g., 1234.56). If you had no coverage for September, leave this field blank.

Enter the Marketplace’s second lowest cost silver plan (SLCSP) premium amount for the ninth month (September) in Part III, Column B. Input the value in dollars and cents (e.g., 1234.56) without a dollar sign or commas. If no premium applies, enter 0.

Enter the dollar amount of the advance payment of premium tax credit applied on your behalf for September 2023. Use whole dollars only (omit cents and the dollar sign). If no advance payment was made for September, enter 0.